The Organization of Medical Care -- Lessons from the Medicare End Stage Renal Disease Program

. . . The participants in the debate about the reorganization of U. S. care have taken little notice of the experience with existing health systems organized by our government. The Medicare program that provides for patients with end-stage renal disease (ESRD) is 20 years old;, it has been the subject of extensive review and analysis. Over the 20 years, the Medicare End Stage Renal Disease Program has demonstrated of the virtues and problems of modern high-technology medicine. Hundreds thousands of Americans have enjoyed extra years of good-quality life the program lowered financial barriers to lifesaving technology. , the quality of life achieved by some patients on dialysis has been, and costs have escalated far beyond the original expectations. The of the End Stage Renal Disease Program have not been applied to the debate about health care reform. My purpose is to review the program this perspective. The dialysis machine has been described as "a metaphor modern technological medicine"; the implications of this metaphor for policy deserve careful scrutiny.