Unlike in the United States, cancer patients in Britain are spared not only the high cost of death but also the agony of painful therapies. Terminally ill cancer patients in Britain are often sent to hospices, where they are given heroin injections to ease their pain. The British solution seems sensible, but with one caveat. In Britain, as in America, the money is controlled by bureaucracies, not by patients and families. So itís not clear whether the choice of a hospice over continued treatment reflects family preferences or bureaucratic rationing. Cancer patients with the potential to be cured are much better off in the American health care system.

It is interesting, once again, to contrast health insurance with life insurance. Prudential Insurance Company in some cases pays life insurance benefits to terminally ill patients prior to their death. Other insurers are considering following suit, on the theory that people should be able to enjoy their death benefit in the last months of life. Because the primary health insurer of terminally ill patients is the federal government (Medicare), we are not likely to see innovation on the health insurance side. But there is the opportunity to merge the British approach to terminal illness with the approach of U.S. life insurance companies. Patients could be given a choice to take some portion of the money that would be spent on high-technology care and use it to live out their remaining months in a more pleasant hospice environment - or, for that matter, to take a Caribbean cruise.

Return to Treatment Of Terminally Ill Patients

U.S. DIALYSIS PATIENTS FACE POORER OUTCOMES

In 1973, dialysis for those with failing kidneys became the first disease-specific treatment universally covered by federal law. Yet hemodialysis patients in the United States face poorer outcomes than those in other industrialized countries, reports the American Medical News.

The death rate for dialysis patients in the U.S. is 23.6 percent -- more than twice as high as in France, Germany, Japan and the United Kingdom in 1992, according to the latest figures available.

• Even after adjusting for age, condition and other patient characteristics, the U.S. mortality rate is significantly higher.

• The primary reason for the higher mortality, say some observers, is that U.S. patients are under-dialyzed.

They say that managed care plans and Medicare dialysis centers limit treatment time, reuse supplies and use poorly trained staff to cut costs.

• For instance, the Medicare reimbursement rate for dialysis has been $126 a session since 1983, although costs have risen significantly.

• By comparison, in France dialysis is reimbursed at more than $700 per session.

• Just since 1988, nondialysis costs for end-stage renal disease patients covered by Medicare have risen from 40 percent to 66 percent, says Smith Barney and Vector Securities.

• The higher cost is partly a result of more hospitalizations due to complications.

Many dialysis patients receive heavy treatment three times a week, which some experts say causes dangerous fluctuation of toxins. One study found that urea levels fell by more than 40 percent with 90-minute sessions six days a week.

Experts say the best therapy for patients able to do it is in-home dialysis, which allows frequent treatment. In 1973, 40 percent of end-stage renal disease patients -- and 90 percent of patients at some centers -- were on home hemodialysis. But the number of home dialysis patients has fallen to less than 1 percent -- and machines designed for use in treatment centers are too complicated, expensive and bulky for home use.

New dialysis systems for home use awaiting Food and Drug Administration approval would cost an estimated $18,000 per year -- $2,000 less than Medicare pays for in-center treatment.

Source: Greg Borzo, "Home is where the Hemo is," American Medical News, October 7, 1996.