Editor's note: Like it or not, the de facto leaders of U.S. dialysis care are the chief medical officers of the two largest for-profit dialysis providers, Drs. Franklin Maddux and Allen Nissenson. They have the onus of practicing medicine in corporations that must service hundreds of millions of junk-bond debt and efficiently utilize existing infrastructure. This reality will continue to push most patients into treatment regimens that virtually no nephrologists would choose for themselves.
What is basically wrong with U.S. dialysis care is its perverse financial incentives. U.S. nephrology embraced junk-bond financing of dialysis facility acquisitions, with many prominent U.S. nephrologists becoming multimillionaires. In light of international comparisons, the longer time that the American Society of Nephrology and the Renal Physicians Association wait to address these economic issues, the more harm they are doing to patients. Unfortunately, we will likely have to wait for this generation of wealthy and influential nephrologists to retire before any meaningful discussions can occur about the extent of the damage their actions caused to patients.
But all is not lost.
U.S. research nephrologists have focused on a "sick patient" model of care since the mid-1970s, putting nearly all their efforts into reducing mortality and hospitalizations. The ESRD QIP program, ESCOs, and integrated care models are all extensions of that sick patient model. Progress has been slow, with improvements in dialysis outcomes ─ and especially quality of life ─ lagging far behind other fields of medicine.
Before 1972, U.S. nephrology had a "well patient" model of care. It was also a time of rapid innovations that did not require randomized controlled trials. A strong financial incentive to restore an integrated well patient model could turn the for-profit corporations into innovators and real patient advocates. Extending the private insurance period for employed dialysis patients, in some regulated form, would drive changes in both their treatment regimens and infrastructure to benefit all patients.