

"God help you. You're on dialysis." - davi
http://www.theatlantic.com/magazine/print/2010/12/-8220-god-help-you-you-39-re-on-dialysis-8221/8308/

======
jdietrich
Dialysis is a proxy issue.

The majority of renal failure in the US is the result of diabetes or
hypertension. The huge increase in the number of dialysis patients is
overwhelmingly attributable to these two causes. In the vast majority of these
cases, renal failure can be prevented with relatively inexpensive intervention
to better manage the primary condition.

In most other developed countries, it is politically straightforward to spend
$20,000 a year on coaxing and cajoling a patient into managing their diabetes
better in order to prevent them from becoming a $70,000 a year dialysis
patient. Needless to say that the benefits to this approach are greater than
just a cost saving.

The United States has a quite peculiar set of popular attitudes to healthcare.
It is clear that a large number of US citizens believe that healthcare ought
not be a universal right, but most also find it unpalatable to simply allow
people to die of preventable diseases. Consequently, cheap early intervention
to preserve health is often shunned in favour of expensive, late intervention
to prevent death. To my mind the most egregious example of this is drug abuse
and alcoholism - huge amounts are spent on ER care for disastrously ill
addicts, but little is spent on basic social work and rehabilitation.

I can't honestly say that I understand the mindset that completely opposes
government involvement in healthcare, but it seems obvious to me that the
current situation is the worst of all worlds - the worst outcomes and the
highest costs. I don't know how healthcare became such an ideological
battleground, but it's not doing anyone any good - not patients and certainly
not the taxpayer. I really don't want to be negative, but I have no idea how
this stalemate can be broken.

~~~
dantheman
The mindset that is against government healthcare is one based on a clear
conception of natural rights theory. It recognizes the validity of negative
rights and the complete contradiction that is positive rights. Though most
aren't against providing healthcare through non-coercive means such as private
charity.

~~~
_delirium
Very few people in the U.S. fully oppose a positive right to health-care
though. They're against a positive right to see a doctor and get regular
treatment, but are _in favor_ of a positive right to receive emergency-room
care if necessary. Hence, ERs are required to treat heart-attack and stroke
patients who show up on their doorstep, even if the victim is uninsured and
has no ability to pay; turning them away is illegal.

So the question isn't over whether there's a positive right to health care---
almost everyone agrees there is to some extent. The disagreement is over which
kinds of care are included in the right.

~~~
robryan
The deeper problem here may be though that treating an emergency patient that
is dying thus requiring immediate care they can't afford could run higher
costs that the appropriate preventative treatment they were unable to afford.

Morally we are obligated to save the emergency patients life but also morally
we shouldn't have let their condition slip to the point it is in.

------
arn
As a former nephrologist I feel obligated to comment on this article. So, much
of what is written is true, but much is also a bit slanted too.

So, mortality rates on dialysis do suck. It's not necessarily a reflection of
bad care, though that certainly happens. Once you require dialysis, that means
your kidneys are trashed. They don't work well enough to function, so you need
kidney replacement therapy. This generally doesn't happen in isolation. If
your kidneys are that damaged, you generally have serious underlying health
problems (diabetes, high blood pressure) that have also affected your brain
and heart... so it's only a (short) matter of time before you have a
devastating event.

There are diseases which only affect the kidneys in isolation, and those
people tend to live a long time on dialysis.

The comparisons to foreign countries is always important but I feel like the
article dismisses some of the country-specific factors

 _"Yet Italy spends about one-third less than we do per patient. These results
reflect lower overall health-care costs and a __patient population with lower
rates of diabetes and heart disease__, but also important divergences in
policy and practice."_

Less diabetes and heart disease would be a huge factor in the difference in
spending and mortality rates. Those are massive implications, and also
indicate that their dialysis patients might be due to different (less
systemic) diseases.

In the end, it's probably only one factor. I think it's likely that underlying
U.S. cultural differences are another. I believe expectations and beliefs
about death and elderly may be different abroad, though I don't have any
citations for that. In the U.S., it's seems hard to deny people dialysis. I'd
be curious what the average age of people on dialysis in the U.S. vs abroad
are. I expect the U.S. average age would be much higher.

I think american families tend to want dialysis and are more reluctant to
accept that it's simply the end of the line. To be fair, it's a hard decision
to not accept what seems to be a life extending treatment. And it's incredibly
hard as a physician to refuse dialysis to anyone, especially if the family
wants it.

I also expect these same attitudes pervade u.s. trained physicians who may
skirt these subjects of death more apprehensively because they also share
those attitudes. The cover your ass mentality also tends to mean people err on
the side of doing more, when doing less may be more appropriate.

~~~
matrix
Slightly off topic: what prompted you to leave nephrology? That's not
something someone would do lightly, to say the least.

~~~
arn
<http://news.ycombinator.com/item?id=236308>

Previous thread on it.

In summary, my side business (macrumors.com) became successful enough that it
made significantly more than my income as a doctor. Combine that with the
lifestyle of being a doctor being bad, and wanting to spend more time with my
young kids. It was still a hard decision at the time due to the sunk costs of
becoming a doctor but on paper it was an easy decision.

------
stretchwithme
The pattern with the government is the same from situation to situation.

1) They make something free

2) The market for private delivery of the same thing dries up. Those few that
still want to pay must pay much more than they would have before the
government started giving it away for free because the market has shrunk so
much

3) The same thing happens to alternatives to the thing they made free

4) Decisions are now made by those delivering the process instead of the
person choosing between the alternatives. Costs and benefits are no longer
weighed together or by the person that cares about the outcome the most.

5) The corporations and unions move in and start influencing the decision
makers, carving out expensive niches for themselves

6) Things that truly matter but aren't profitable for the politically
connected fall by the wayside

7) People getting something free put up with it because ditching the free
thing for same thing done right is now a super expensive alternative

8) Delivering the free thing grows more expensive, much faster than the rate
of inflation

9) Eventually the tax payers fight back and the costs of delivering the thing
are slashed, along with quality. The corporations and unions have to spend
and/or threaten more to hang on to their protected positions.

10) Those getting the service for free now have to spend all their time at
rallies and fine tuning the stories about how badly they're being treated.

Happens with health care. Happens with roads. Education. City services.
Anything they give away for free or heavily subsidized.

~~~
knowtheory
I'm not going to claim that undergraduate education in the US is perfect or
anything, but we do have a world class education system which rivals or bests
all other nations'. And on top of that, i would say that my publicly
subsidized education was just as good if not better than many private
educational experiences, and it was a whole hell of a lot cheaper.

And i grew up in a city with one of the best public library systems in the
country. You'll still notice that it was populated with plenty of Barnes &
Nobels and Borders book stores.

Oh, and i'll note that the Ambassador Bridge, the Blue Water Bridge and
basically any bridge in and out of Ontario to the US are privately owned toll
bridges, which charge you to travel over them.

[edited to remove pointless but cathartic ad hominem]

~~~
jerf
We're in the late phase of step 8 for undergraduate education. Let me know in
10 years if you still think everything's peachy with it. The signs of strain
are already there if you know where to look, but I'm pretty sure by 2020 you
won't be able to pretend otherwise. Probably by 2015. Possibly by this time
next year. (Personally I'm thinking that barring a major economic turnaround
we see a distinct drop in college enrollment next year.)

You also don't know which is cheaper, public education or private. You know
that in a government-subsidized environment, public was cheaper to you than
private, but what a freaking surprise, when you pay for public school whether
you attend or not, then must pay for the private school on top of that. Of
course X + Y > X... but school's only _free_ if you never pay local taxes.

~~~
stretchwithme
The government is very adept at pointing out what handouts people are getting
and hiding how much its actually costing them. And it seems to work on plenty
of people.

------
kleinmatic
This project was done by ProPublica, the nonprofit reporting outfit where I
work. There's more from the same investigation at
<http://www.propublica.org/dialysis> including a leaked P.R. plan drawn up by
an industry group to respond to our investigation -- and there's lots more to
come in the next few weeks.

~~~
knowtheory
what's it like working at ProPublica, and what do you do there? I've liked
everything i've ever read/heard that's been produced there, and i know they've
got good taste in terms of the journalists they poach from other orgs.

~~~
kleinmatic
Thanks for the kind words about ProPublica. It's exciting to be around so many
talented journalists and to get to work on great projects with them.

I run a small team (five of us) of developer/journalists. We're in a new-ish
field of journalism called "news applications." Essentially it means we make
software instead of using words or pictures to tell journalistic stories.
There are crews like ours (some bigger, some smaller) at the New York Times,
LA Times, Chicago Tribune, the Guardian in the U.K., and elsewhere.

Our work includes the Recovery Tracker
<http://projects.propublica.org/recovery> and the recent "Docs for Dollars"
project <http://projects.propublica.org/docdollars> that analyzes payments
from pharmaceutical companies to doctors.

You can see pretty much all of our work at <http://www.propublica.org/tools>

------
jfb
I worked IT for the University of Chicago hospitals for a while in college,
and was responsible for the systems at the dialysis center on 55th street. It
was utterly heartbreaking to me; the stoicism of the patients (the vast, vast
majority of whom were locals in the UofC parlance -- read, "black and poor"),
the genuine hard work of the nurses and nurses aides; and just the overall
sense of agony in the building. It was rough, and only made rougher because I
could _leave_.

------
aheilbut
It would seem that the ultimate solution to this problem would be an
implantable artificial kidney. Given that the technology for dialysis has been
around for so long, it's surprising that there hasn't been more progress in
miniaturization over the last 40 years.

~~~
CapitalistCartr
Much of these problems with artificial organs revolve around the power supply.
An artificial heart is pretty easy with modern technology compared to how to
power it. Same for most organs.

~~~
cdavid
Dialysis also requires expensive medicine, like e.g. EPO, which contributes to
a non negligeable part of the cost. The 77000 $ / patient surprised me a
little because the figures I have heard in France (family members involved in
dialysis treatment)are actually higher, not lower.

