Controlling health care spending: unintended consequences of a fragmented approach

Health care policy decisions in Washington are being driven almost entirely by budget considerations and Presidential politics. The public programs, Medicare and Medicaid, have been targeted for drastic cuts ("decreases in growth"), which could have devastating effects on the millions of people who rely on the services provided through these programs, including patients with end-stage renal disease (ESRD). Very little is being said about the overall growth of health care spending, with private sector growth continuing to outpace general inflation. Fragmenting the approach to health care reform, focusing only on the public programs, could lead to significant unintended consequences in the system as a whole, including less affordable health insurance and increasing numbers of uninsured. For nephrology, significant reforms should be developed and promoted by health professionals to assure the viability of the ESRD program, and the continued delivery of the highest quality care to ESRD patients. These should include: management of demand for dialysis services; enactment of health insurance reform; active participation in the growth of managed care in the ESRD area, and the HCFA Demonstration Project of ESRD Capitation; reexamination of the role of home dialysis, particularly home hemodialysis; development of new care delivery paradigms, including the expanded use of physician extenders.