Garella S
Department of Medicine, St Joseph Health Centers and Hospital, Chicago, IL 60657, USA.
Nephrol Dial Transplant. 1997;12 Suppl 1:10-21.
End-stage renal disease (ESRD) is unique in that, in the United States, it is the only disease-specific condition covered by Medicare independently of the age of patients. Medical care to these patients is provided through 2506 facilities, most of which are free-standing. Of these, the majority are operated by profit-making concerns. The total number of patients served by the Medicare ESRD programme has increased each year and in 1995 it is estimated to be approximately 260,000, of which 195,000 are treated with maintenance dialysis, largely in-centre haemodialysis. Total expenditures for the ESRD programme (of which Medicare is responsible for approximately 72%) in 1995 are projected at $12.3 billion, of which Medicare is responsible for approximately $8.9 billion. Close to 50% of the expenditures are related to the provision of maintenance dialysis. The major component of these expenses is attributable to the Medicare 'composite' reimbursement fee, a fee the amount of which is established by Medicare to reimburse dialysis units for the provision of maintenance dialysis, independent of the costs that the unit might incur. This 'composite' fee has decreased substantially in the course of the last 20 years. The mortality of patients on dialysis in the USA remains high. This is in part due to the increasing severity of associated illnesses and more advanced age of the patients. However, the dose of delivered dialysis in the USA remains less than that observed in other industrialized countries. Three factors appear to play important roles in keeping the dose of dialysis low: the Medicare reimbursement method, the fiscal pressure on dialysis units to generate revenues, and patient preferences. There is general agreement that an increase in dialysis dose will be necessary to reduce mortality. However, this increase would be accompanied by increased costs to the providers of treatment. Improvements in the dose of dialysis to patients (and hence, it is hoped, in morbidity and mortality) are not likely to occur unless Medicare reimbursement increases and is designed to provide financial inducements to improve care and outcomes.
终末期肾病（ESRD）在美国具有独特之处，它是医疗保险独立于患者年龄所覆盖的唯一特定疾病状况。为这些患者提供的医疗服务通过2506家机构进行，其中大多数是独立的。在这些机构中，大多数是由盈利性企业运营的。医疗保险ESRD计划所服务的患者总数逐年增加，1995年估计约为26万，其中19.5万接受维持性透析治疗，主要是中心血液透析。1995年ESRD计划的总支出（医疗保险约承担72%）预计为123亿美元，其中医疗保险约承担89亿美元。近50%的支出与维持性透析的提供有关。这些费用的主要部分归因于医疗保险的“综合”报销费用，该费用数额由医疗保险确定，用于向透析单位报销维持性透析的费用，与单位可能产生的成本无关。在过去20年中，这种“综合”费用大幅下降。美国透析患者的死亡率仍然很高。部分原因是相关疾病的严重程度增加以及患者年龄更大。然而，美国提供的透析剂量仍低于其他工业化国家。有三个因素似乎在使透析剂量保持较低方面起着重要作用：医疗保险报销方法、透析单位创收的财政压力以及患者偏好。人们普遍认为，增加透析剂量对于降低死亡率是必要的。然而，这种增加将伴随着治疗提供者成本的增加。除非医疗保险报销增加并旨在提供经济激励以改善护理和治疗结果，否则不太可能提高给患者的透析剂量（从而有望改善发病率和死亡率）。
