Socioeconomic impact on ESRD?

This blog post is reposted here with permission from DaVita Kidney Care.

Before I get started opining about my observations of the socioeconomic impact on end stage renal disease (ESRD), let me state that I am not an expert on this critical science and its implication on health care. Rather—after practicing 25 years in Detroit, once a proud city boasting the highest per capita income in the world (in 1960)—I am, as a physician, a keen observer of the impact of a failing city, its resources and its support systems on our most vulnerable citizens.

Priorities. We all have them, right? Family. Work. Church. Oh yes, and health care. Of course it’s there if or when you need it, right? That little card in our wallet is our safety net. Our focus on health care as a priority changes as we age or if we develop a chronic condition requiring attention.

One may argue that the above image is a concocted anomaly predicated on employment and therefore a vision held by the employed. So what of others, the chronically unemployed or even the recently unemployed, the less fortunate among us? What happens when the support system collapses around them?

Who “goes” first? The least educated, those with the fewest social skills and those with the poorest family support. No little card for them. They tend to be minorities; today it’s African Americans or those of Hispanic descent, but a century ago it was the Italians, Germans, Irish and others coming to the dream of America with little.

But haven’t we fixed the health care “sins” of the past? Yes and no.

But doesn’t everyone have access to health care? They can’t be denied, right? True—sort of. All patients can go to the emergency center for “emergency” care. No one with an active disease can be turned away, regardless of his or her ability to pay: a just law. The Emergency Medical Treatment and Labor Act passed in 1986 . . . but then what?

If you have no resources you may receive Medicaid, but here is where things get sticky.

Let’s go back to priorities. Once an acute event passes, so does interest in chronic follow-up. In a bureaucratic system such as Medicaid or Veterans Affairs or the State Children’s Health Insurance Program (or . . . shall I go on?) finding health care providers willing to offer care at a loss is near impossible, particularly if you have no transportation or the buses in your city don’t run and you have no money for a cab and so on.

So what about individual responsibility? I’m all for it! Unless, of course we overpromise what a health care safety net provides, give false hope and then point fingers when the system fails. Is this what we have done? To some extent, I believe so.

But so what—won’t this all work itself out? Well, it hasn’t yet. Let’s focus for a moment on ESRD.

Just today, a homeless patient of mine missed his dialysis appointment because he had no “ride.” He was able, however, to call 911 and take three (yes, three) trips to three different emergency rooms. The first two saw no acute reason to admit him and finally the last acquiesced. Wow; couldn’t the ambulance have brought him to the dialysis facility? No, regulations prohibit that. Could the dialysis facility pay for a cab? No, regulations prohibit that too; and on and on. How are homeless people supposed to deal with this? They’re not.

If we look “upstream” at this man’s care, when he had chronic kidney disease (CKD), could we have done better?

Who is predisposed to CKD and ESRD? Sadly, the precise population that the medical safety net has promised to help: the socioeconomically disadvantaged remain disproportionally at risk. This risk is compounded by regulations purported to prevent physician fraud and abuse.

These regulations bind patients and their caregivers to an arcane system that serves bureaucrats rather than patients; one that refuses to acknowledge something as simple as the need for provider transportation to satisfy medical needs and avoid emergency-room visits.

Although I agree there is no simple fix to this chronic problem, we must start somewhere. Regulators must have a better understanding of the actual impact of regulations on patient care. With integrated care we were promised an easing of these regulations—but as of yet that has been unrealized.

The “value proposition” to the health care system should be obvious. We can do better. We should do better. Our most vulnerable patients deserve better! -by Robert Provenzano, MD, FACP, FASN