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Preventing Kidney Failure


Every year, 100,000 patients go on dialysis; the average survival at this point is 2.5 years.  Patients do not go on dialysis until they have profound, irreversible kidney failure, with severe side effects; even when your serum creatinine is five times normal, it’s still not yet time.  Over ten years ago, a classmate of mine published his discovery that high doses of irbesartan given to patients with hypertension and proteinuria (due to diabetes type 2) can prevent progression to renal failure and dialysis.  If this treatment were applied to all or most of the 100,000 patients who were destined for dialysis, say five or ten years before their endpoint, Dr Moskowitz estimates that it would eliminate 90% of these failures.

However, since the publication of his discovery, and despite his concerted efforts to contact the people in charge of administering the health issues related to renal failure, nothing has been done to publicize the treatment, promote its use, or attempt to move forward with the real prevention of renal failure.

Dr David Moskowitz (Harvard College class of 1974, Harvard Med School 1980) has written a very nice paper about this problem and his efforts; the pdf version is here:

His proposal for helping to resolve the systemic problem that he has encountered is very neat and I quote it here, from the end of his article:

“Just mandate reporting of health outcomes for every patient whose healthcare is paid for with federal dollars.  Post clinical outcomes for every physician and every hospital on the web, for all to see… Let patients vote with their feet.”

He has re-discovered the fact that the business model of medicine requires disease.  Patients must get sick for the revenues to continue flowing.  If no-one gets sick, the providers of healthcare don’t make any money.  The reverse should be true.  Providers should make more money from preventing illness than from treating sick people.

In his attempts to publicize his preventive treatment, he has found that those in charge of administering treatment for kidney failure patients are more concerned with managing their ill patients than reducing their number.  This is, in part, a consequence of the lucrative marketplace for dialysis funded by Medicare dollars.  It is also, in part, due to the vested interests of those who administer populations of sick people; reducing the number of sick people in any context reduces their revenues.

The key is to look at the cost of treating illness, then invert the payment model so that maximum dollars are available at the outset, when the patient is healthy.  Then the dollars diminish progressively as the patient’s illness appears and gets worse; dollars are retained if the patient doesn’t get sick.  This is more of a virtual model than a real one, because, for example, the cost of a smallpox vaccination is vastly less than the cost of treating a case of smallpox.  It doesn’t make sense to pay someone, say, $50,000 for administering a smallpox vaccination and $10 for a week in the hospital with smallpox.  But it does make sense for the government to do some mental accounting and invest $10 million in a smallpox eradication program with the hope of saving some money on hospital costs in the long run: if you prevent 200 cases of smallpox, you’ve spent minus ten million dollars, and you make all your money back.  (Assuming that your hospital doesn’t depend on a steady stream of smallpox cases to make a profit.)

This type of accounting is impossible for an individual or a profit-making corporation but essential for a government.  Thus we come back to the fact that government is essential for some functions of society in order to improve our conditions of life.

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