Table Of Content# 16 of
INSTITUTE OF MEDICINE
PREPUBLICATIONCOPY
Kidney Failure and the
Federal Government
Publication:Summer1991
ADVANCE COPY
Not For Public Release Before:
Wednesday, April 17, 1991
EDT
6:00p.m.
KIDNEY FAILURE AND
THE FEDERAL GOVERNMENT
Committee for the Study ofthe Medicare ESRD Program
Division ofHealth Care Services
Institute ofMedicine
Richard A. Rettig and Norman G. Levinsky, editors
National Academy Press
Washington, D.C. 1991
.
Notice: The project that is the subject of this report and its
technical appendices was approved by the Governing Board of the
National Research Council, whose member are drawn from the
councils of the National Academy of Sciences, the National
Academy of Engineering, and the Institute of Medicine. The
members of the committee responsible for this report were chosen
for their special competencies and with regard for appropriate
balance.
The Institute of Medicine was chartered in 1970 by the
National Academy of Sciences to enlist distinguished members of
the appropriate professions in the examination of policy matters
pertaining to the health of the public. In this, the Institute
acts under both the Academy's 1863 congressional charter
responsibility to be an adviser to the federal government and its
own initiative in identifying issues of medical care, research,
and education.
This study was supported by the Health Care Financing
Administration, U.S. Department of Health and Human Services,
under Cooperative Agreement No. 14-C-99338/3-02
Publication IOM-91-06
Library of Congress Cataloging-in-Publication Data
Library of Congress Catalog Card No. XXX
International Standard Book Number XXX
Institute of Medicine (U.S.). Division of Health Care Services
The Medicare End-Stage Renal Disease Program
This report "The Medicare End-State Renal Disease Program"
is available from the National Academy Press, 2101 Constitution
Avenue, N.W. Washington, D.C. 20418
,
Copyright 1991 by the National Academy of Sciences
No part of this book may be reproduced by any mechanical,
photographic, or electronic process, or in the form of a
phonographic recording, nor may it be stored in a retrieval
system, transmitted, or otherwise copied for public or private
use, without written permission from the publisher, except for
the purpose of official use by the United States Government.
Printed in the United States of America
Committee for the Study of the
Medicare EBRD Program
NORMANUniG.verLsEiVtIyNSKSYch,ooMl.D.of, MCehdaiirc,ineD,epaBorsttmoenn,t MoafssMaedcihcuisneet,tsBoston
CARMEWLhLaArtAo.n,BOCNCeHwINJOe,rseR.yN., M.B.A., Health Care Consultant
CLIVE 0. CALLENDER, M.D., Department of Surgery, Howard
University Hospital, Washington, D.C.
CHRISTINE K. CASSEL, M.D., Department of Medicine, The University
of Chicago Medical Center, Chicago, Illinois
ROGER W. EVANS, Ph.D., Battelle Human Affairs Research Center
Seattle, Washington '
RONALD M. FERGUSON, M.D., Ph.D., Department of Surgery, Ohio
State University College of Medicine, Columbus, Ohio
SHELDON GREENFIELD, M.D., New England Medical Center Hospitals
Boston, Massachusetts
PHILIP J. HELD, Ph.D., The Urban Institute, Washington, D.C.
SUSAN M. JASKULA, M.S.W., Renal Dialysis of St. Louis, Inc., St.
Louis, Missouri
J. MICHAEL LAZARUS, M.D., Department of Medicine, Brigham and
Women's Hospital, Boston, Massachusetts
JOHN E. LEWY, M.D., Department of Pediatrics, Tulane University
School of Medicine, New Orleans, Louisiana
C. RICHARD NEU, Ph.D., The RAND Corporation, Santa Monica,
California
MAJORIE J. POWERS, Ph.D., R.N. Department of Medical and
Surgical Nursing, Universi,ty of Illinois, Chicago, College
of Nursing, Chicago, Illinois
JOHN H. SADLER, M.D., Department of Medicine, University of
Maryland School of Medicine, Baltimore, Maryland
PAUL K. WHELTON, M.D., Johns Hopkins University Schools of
Medicine and Public Health, Baltimore, Maryland
MARSHA WOLFSON, M.D., Department of Medicine, Portland VA Medical
Center, Portland, Oregon
iii
Study Staff
Division of Health Care Services
KARL D. YORDY, Director
RICHARD A. RETTIG, Study Director
JOEL BROIDA (1989)
YEN-PIN CHIANG, Research Associate
ANNE PAGE CHIAPELLA Research Associate
DIANE B. MURDOCK, Re,search Associate
GREGORY P. YOUNG, Research Associate
DOUGLAS JOHNSON, Research Assistant
NAOMI H. HUDSON, Project Secretary
BRENDA A. PATTERSON, Project Secretary
iv
. .
Acknowledgements
This report results from the deliberations of the
tSEhnded-sSjtuSadaggSemenRpteLsn!a?l?ofdDntiChsieenaesceoCm°mPrirtoitgterteae.me afn°dr tihtse rSetucdomymeonfdatthieonMsedirceafrleec"t
wftcih.osemhmeicstTothmeetmeoitamtaceectmeukbanelohrwaslsp,erdebgepseetaanrfaiftta,sicocngoarnmdapotlfiiotsttuhhhdeeeerdrcbfeyooprnotrtrtthihebeuusnctedooelrvrlsae.rctithoieuvTsehdeireefcfcootmrimtoistnteooeff
contributions
and coThnetraccotmmirtetpeoertsthafnokrsthtehierauitnhvoarlsuabolfethienpuctomtmoissthieoned papers
RGdioientcclchlihuab,dreedr:VaitN.citoWoniFrsilnleMio,.afmHJtaoAhwsmeteenhcdoRo,r.mnmeMiG,aatrrtcjePioehari,ilaeinpdDAa.nJt.ioeClHaiehtlnsS,d.,rGeHapPayorrlraoitkln.ad,shI.TFKrheaeFsnsehkeladvAmei.axanphe,rts
2DEirduiCtm^hmoeniT.d RAOewbnenrilfee9,y,,ASsMUhaSraknSegVL.h'alPL,aauuldJyoe,nciantAahn,annaBPSeehrsoncwaesr,tdacVLkoi,,ctoNarnadthE.aCnonPswo.tlalnaLcceevki'ns,
Thomas. Their specific papers and reports are listed in Appendix
C. In particular, it thanks Robert A. Wolfe for his essay
p"rSougrrvaimvalofaMneadliycsairse,m"ethpoudbslisfhoerdthase AEpnpdenSdtiaxgeD.Renal Disease'(ESRD)
The committee expresses its appreciation to those
individuals and organizations who testified before its two public
pwnhaooerrnatkwrishicihntgoiesppsanr(teoAsnnpaplEienSnRfdDtiahcieelssutrapefaEftiipaneangntd,tieF)nkftio,sdcuntseo(yAgtprhtpoereuanpnpdssiapxrlt(aiGA)ncptip,apetaaninndotdinsx,toHi)natndhteheblatchkreeand
The committee benefited from the work of the following
cEroenssiualnt,antJsu:dithMarR.ciaLavFe.,ClDaarlke,LuBpeut,tyNaC.omiCraNnadiaelrlm,an,JohanndG.Winfred
W. Williams.
The committee wishes to acknowledge the specific
contributions of the following individuals to the particular
chapters of the report. The study director, Richard A. Rettig,
had primary responsibility for preparation of the report. He and
the committee chairman, Norman G. Levinsky, edited the entire
YdcoooucnnutgmreinbatundtoarnEsdditpthorepTs.apreecOdbiefritlcheeyc;hSaupCmthmeaarprstyerwaenrd3e,:CChharpCithseatrpitne1e.r K2.,TheGCarseosgteohlre,yr APlvin
AW.nneMosPs.,ChRiiacphealrlda,A.wiRtehttitgh,e aansdsisNtoarnmcaen Go.f PLaeuvlinsW.ky;EggCehrasp;terCha4,pter
RY5,ioucnhAgan;rndeCAhP..apRtCeehtritaip7g,e,llGarG;ergegoCorhryayptP.eP.rYoY6,ouunngYge,na-ndPainndYeDnCo-huPigialnnagsChainJadonhgnG;sroengC;ohraypCtheaP.rpte8,r
9, Diane B. Murdock and Yen-Pin Chiang; Chapter 10, Richard A.
v
Rettig and Yen-Pin Chiang; Chapter 11, Diane B. Murdock and Yen-
Pin Chiang; Chapter 12, Richard A. Rettig, Sheldon Greenfield,
John H. Sadler, and Klemens B. Meyer; Chapter 13, Richard A.
Rettig; and Chapter 14, Richard A. Rettig and Anne P. Chiapella.
Several members of the Institute of Medicine's professional
staff contributed to this report. Karl D. Yordy, as Director of
the Division of Health Care Services, provided valuable guidance
over the duration of the project. Marilyn J. Field made very
useful comments on a draft of Chapter 9, 10, and 11. Similarly,
Kathleen N. Lohr reviewed a draft of Chapter 12 and, during the
time the two projects overlapped, kept us informed of the
progress of the Institute of Medicine's study of guality
assurance in the Medicare program.
The study and the resulting report would not have been
possible without the dedicated support of the IOM staff,
including Naomi Hudson, project secretary in 1990; Brenda
Patterson, project secretary in 1989; H. Donald Tiller,
administrative assistance; Lisa Chimento and Nina Spruill,
financial specialists. Wallace Waterfall provided helpful
editorial advice.
Finally, support for this study was provided by the U.S.
Department of Health and Human Services, Health Care Financing
Administration, through a cooperative agreement (No. 14-C-
99228/3-02). At HCFA, we thank Charles Booth and Bernadette
Schumaker, Bureau of Policy Development; Paul Mendelsohn and
Suzanne Rohrer, Health Standards and Quality Bureau; Kathy Sagel
and Roger Milam, Bureau of Data Management and Strategy; and Paul
W. Eggers and Joel Greer, Office of Research. Our special thanks
go to Carl Josephson, project officer, Office of Research.
vi
LIST OF TABLES
1-1 Incidence of New Patients and Prevalence of Patients in
Medicare End-Stage Renal Disease (ESRD) Proqram. 1974-
89
1-2 New Elderly and Diabetic End-Stage Renal Disease (ESRD)
Patients as a Percentage of New Medicare ESRD Patients
1-3 Projections of Medicare End-Stage Renal Disease
Patients to the Year 2000
1-4 Cumulative Percentage Change in Medicare End-Stage
Renal Disease (ESRD) Benefit Payments, 1974-88 Nominal
and Real Dollar Payments
1-5 Growth of End-Stage Renal Disease (ESRD) Program:
Patient Growth Versus Real-Dollar Benefit Payment
Growth
1-6 End-Stage Renal Disease (ESRD) Benefit Payments by Type
of Service, 1988
1-7 Medicare End-Stage Renal Disease (ESRD) Benefit
Payments, 1974-88
1-8 End-Stage Renal Disease (ESRD) Expenditures in
Department of Veteran Affairs, 1984-89 (millions of
dollars)
4-1 Age of New Dialysis Patients, 1960-67
4-2 1967 Projections of New End-Stage Renal Disease
Patients, 1968-77
4-3 New End-Stage Renal Disease Patients by Age, Gender,
Race, and Primary Diagnosis, 1978-89
4-4 New End-Stage Renal Disease Patients per Million
Population by Age, Gender, and Race, 1987
4-5 New End-Stage Renal Disease Patients per Million
Population by Primary Diagnosis, Gender, and Race, 1988
4-6 Prevalent End-Stage Renal Disease Patients, 1978-89
4-7 Gross and Unadjusted One-Year Mortality for All End-
Stage Renal Disease (ESRD) Patients, 1978-88
vii
4-8 Mortality for Medicare End-Stage Renal Disease (ESRD)
Patients (ever-entitled) Adjusted For Age, Race,
Gender, and Primary Diagnosis, 1978-88 Patient Cohorts
4-9 One-Year Mortality (percent) for All End-Stage Renal
Disease Patients, at Year of Incidence, by Age, Gender,
Race, and Primary Diagnosis, 1978-88
4-10 One-Year Mortality (percent) for Dialysis Patients at
Year of Incidence by Age, Gender, Race and Primary
Diagnosis, 1978-88
4-11 Five-Year Survival of Dialysis Patients by Country and
Diagnosis of Diabetes
4-12 Medicare End-Stage Renal Disease (ESRD) Population
Projections, Year 2000
5-1 Incidence and Prevalence of Pediatric End-Stage Renal
Disease Patients, 1978 and 1987
5-2 Percentage of Pediatric Patients with Functioning
Graft, 1978 and 1987
5-3 Pediatric Patient Survival (percent) at One Year by
Year of Incidence and Age Group, 1978 and 1987
5-4 New End-Stage Renal Disease Patients in 1978 and 1988,
by Age Group
5-5 Patients with Diabetic Kidney Disease as a Percentage
of Total Patients, by Age Group
5-6 Percentage of U.S. Population with Definite
Hypertension, 1976-80
5-7 Incidence of Treated Hypertensive End-Stage Renal
Disease per 10 Million Population by Age Group for
Blacks and Whites in 1988
5-8 End-Stage Renal Disease Treatment Modalities (percent)
for Blacks and Whites on December 31, 1980, 1984, and
1988
5-9 Survival of Black Versus Other Dialysis Patients by
Year of Incidence
6-1 Growth of Outpatient Dialysis Providers, 1980-88
6-2 Definitions of Dialysis Unit Size, Demand, Capacity,
and Utilization
viii
