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March 29, 2011

Taking on the Global Challenges of Nephrology

6 Comments to “Taking on the Global Challenges of Nephrology”

  1. Bob Gutman said,

    April 4, 2011 @ 9:04 am

    I (and therefore you) am being swamped with “reply all” responses to Allen. All agree this is a great idea. Maybe what is needed to avoid chaos is for a relatively specific topic to be picked. Allen has challenged thinking on both the quality and cost control frontiers. They are related but separable issues. Can we start with one? For example, who read the WSJ Front page today on the apparently draconian Republican proposal to reduce Medicare and Medicaid expenditures and at the same time reduce marginal tax rates? http://online.wsj.com/article/SB10001424052748703806304576240751124518520.html?mod=ITP_pageone_0

    I respectfully suggest that we respond to Allen personally without “reply all” unless there is something substantive…in which case, this might be the best venue.


  2. Allen Nissenson said,

    April 4, 2011 @ 9:36 am

    Thanks, Bob for the suggestion on how best to carry out the dialogue without overloading em in-boxes.
    I did see the WSJ article and have the following reactions:
    1. Once again the most vulnerable are targeted – the elderly, disabled, those with ESRD and the indigent.
    2. Concern over high deficits is not only appropriate but critical to the future of this country including its safety net healthcare systems.
    3. I remain mystified by the policy imperative by some to resolve the deficit by lowering taxes and thus revenue to the government. I am no economist but to my simple way of thinking one can lower the deficit by either cutting spending or raising revenue or both.
    4. “Privitizing” the Medicare benefit it the equivalent of eliminating Medicare as a program, since benefits would now be under the control of individual private insurance plans. If this were an option to traditional Medicare it would have to include requirements for minimal benefits, limits to HP overhead, quality metrics, etc. to protect the seniors.
    5. Block grants for Medicaid have been done and lead to massive disparities in how our neediest citizens can get healthcare, depending on where they live. Again, the details are critical here and funding for Medicaid must include uniformity in basic benefits, access to medically necessary care, monitoring of quality.

    Finally, there is no question that controlling costs in healthcare spending in these entitlement programs is essential. But lets get back to basics: a. Provide appropriate preventative care; b. Eliminate/minimize the “middle man” administrative costs taken out of the system in the current insurance structure; c. Minimize variations in clinical practice that drive high costs where evidence is available; d. Eliminate defensive medicine with protection against inappropriate litigation; e. Empower patients to be true partners with providers in ensuring their own health and managing their care when they are ill.

  3. E.P Paganini said,

    April 4, 2011 @ 9:37 am

    I have had the opportunity to travel quite a bit, having been trained in Europe and later visiting both Europe and Asia for a variety of reasons (academic, social, personal etc).
    I am impressed with the major difference in societal responsability as opposed to patient “rights” so frequently evoked here in the States. Although the world may be slowing flattening out, There is a lot to be learned from the tragedy in Japan and their societal response to helping regain their individual returns. No riots, no looting, no major demonstrations, no broad pleas for hand-outs, just honest work and committment to their society!
    Do we really believe this type of attitude will ever migrate here, now that the hills have been flattened and the world is watching?

  4. Steve Rostand said,

    April 4, 2011 @ 9:48 am

    Allen, Better dialysis methodologies and overall better general health care have prolonged the lives of ESRD patients beyond anyone’s wildest imagination in 1972. The original cost figures computed in 1972 were flawed and now costs are astronomical. How can we continue to provide excellent, non-discriminatory care when it is clear no one is willing to pay. Prevention is clearly the best approach but will be vilified as being nannyism. So where does that leave us? Possibiy with having to go backwards to rationing dialysis since In the US there appears to be no stomach for universal medical care.

  5. Allen Nissenson said,

    April 4, 2011 @ 10:53 am


    I think we need to attack this on a few fronts:

    1. CKD risk mitigation
    2. Slow progression/manage CKD patients appropriately
    3. Care coordination to optimize clinical outcomes while controlling cost
    4. Substantial increases in investment in new, innovative technology that will more closely emulate natural kidneys, improve outcomes, disrupt the current treatment paradigm, and constrain costs.

  6. Bob Gutman said,

    April 5, 2011 @ 1:30 pm

    I confess that my first instinct was to argue with Allen that serious cost containment has to be about entitlements and since entitlements are usually for the disadvantaged, he is correct that the vulnerable are necessarily the focus-so his comment contains an element of inevitability; and then to argue that tax rates are not all that closely related to government revenues.

    However, the parameters that he posted above really are the best items for discussion on this venue and there is no argument with that list at all…now let’s consider the details. “Care coordination” might be the most fruitful field to mine and will indeed save lots of money.

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