Employment Status of Patients with ESRD and the Subsequent treatment modalities in the United State

End Stage Renal Disease impacts the lives of over 725,000 Americans and their families. In 1972, despite the cost of supporting a rapidly growing chronic condition at the time, the United States initiated a system whereby everyone would be treated that qualifies for social security benefits, after a waiting period of three years (Medicare Secondary Payer was slowly extended over the years to 36 months after diagnosis as it currently stands), regardless of age, providing the platform for the debate of a potential nationalized health care system that currently seems to be in a period of uncertainty. However, over three decades through significant consolidation, the treatment of dialysis via two large provider chains (one fully integrated) have directed patients to hemodialysis in the out-patient setting without considering the technological or clinical benefits of home hemodialysis or peritoneal dialysis [1,2]. This may have occurred as a result of medical training although the overall system is structured more on a corporate basis today with new nephrologists joining practices that are already contracted with a large chain through medical directorships. That said, patients seem to be directed towards outpatient hemo-dialysis over other options such as home hemo-dialysis and peritoneal dialysis. The result has created an economic and medical system that has shifted toward what is perceived as the lowest cost of care without a consideration for other treatment modalities that promote a better quality of life for the patient as well as greater monetary benefits for the United States Federal Government. From a pure economic standpoint, profitability for providers is in the out-patient clinics despite the initial investment of $1-2 million to build out a clinic via fixed asset utilization and the variable cost of peritoneal dialysis as well as the supply costs needed for home hemodialysis. In other words, for these two treatment modalities, the margin, if any, is built purely into the treatment. Margins can be enhanced through high utilization of in-center facilities via leveraging the staff and fixed costs while using economies of scale to reduce variable costs such as dialyzers and lines combined with a favorable commercial patient base. With the focus on this modality, there are economic impacts based on decisions that increase the overall expenditures to the entire system that can easily be avoided or reduced.