Once long-term treatment of end-stage renal disease (ESRD) became an entitlement under Medicare in 1972, a disorder that had usually been fatal was magically transformed into a chronic condition, but this transformation came with the enormous logistic problem of establishing the dialysis and kidney-transplantation facilities that now keep nearly 400,000 patients alive in the United States. Between 1968 and 1989, National Medical Care, a newly formed company, established the pattern of building and managing free-standing facilities for ambulatory dialysis -- a pattern that has been copied worldwide. In The Price of Access, Tim McFeeley, the former corporate counsel for National Medical Care, recounts (as the copy on the book jacket has it) "a dramatic human interest story with insight into many arenas of medicine, government, and business today." Characterizing kidney dialysis as "one of the great successes in the medical community," McFeeley provides insight into the ways in which the business world accommodates a broadly applicable major advance in medicine. McFeeley chronicles three interlinked narratives: the intrigue-filled history of uremia therapy at Harvard's Peter Bent Brigham Hospital; the story of the social and economic struggle undertaken by Constantine L. ("Gus") Hampers, Theodore Birge ("Ted") Hager, and Eugene Schupak in order to initiate the creation of free-standing, profit-making hemodialysis units; and the story of what went on in the corporate boardrooms as Hampers lost his battle for control of W.R. Grace and sold National Medical Care to Fresenius Medical Care for $4.4 billion in 1995. Hampers, Hager, and Schupak were nephrology fellows at the Peter Bent Brigham Hospital in Boston during the 1960s. Their mentor was the late John Merrill. Although they witnessed repeatedly the success of hemodialysis, the three were frustrated in their attempts to expand the Brigham's dialysis program. In 1966, Hampers and Hager began offering hemodialysis on an outpatient basis in Melrose, Massachusetts, at Normandy House, an underutilized chronic care facility. Hager observed that "after five years of being turned down by government, academia, and the hospital, we got what we wanted from the private sector in just three weeks." Charging $160 for a dialysis session for which the Brigham would have billed $360, the facility immediately won business and filled up. Next, in Brookline, immediately adjacent to Boston, National Medical Care built the Babcock Kidney Center, a 20-station hemodialysis unit that shared a facility with 30 beds for psychiatric patients and 34 beds for extended care. Around the same time, Schupak opened the Queens Artificial Kidney Center at Elmhurst Hospital in New York. McFeeley's story quickens with the intense attack on National Medical Care in the Boston Globe in July 1971, on CBS's 60 Minutes in 1977, and finally, in the New York Times in 1995. Accused of lapses in ethical conduct for mixing medicine and profit (but not accused of offering substandard medical care), the physician-founders of National Medical Care were forced to sever relations with John Merrill's kidney service. Merrill was demoted and replaced as head of the nephrology division. Absent from McFeeley's description of the birth of universal hemodialysis is recognition of the vital contribution of Benjamin T. Burton. Burton created the Artificial Kidney-Chronic Uremia Program of the National Institute of Arthritis, Metabolism, and Digestive Diseases, which supported innovation and improvements in the technique of dialysis throughout the 1960s, 1970s, and 1980s. Also unmentioned is the brilliant leadership of James R. Kimmey, who, under the aegis of Community Health Services Projects, channeled funds from the U.S. Public Health Service to develop 14 demonstration kidney centers in locations ranging from Los Angeles to Jackson, Mississippi, to Brooklyn, New York. Another omission is peritoneal dialysis, which sustained 7 percent of patients with ESRD in 1999. Errors in details mar the exciting story of how maintenance hemodialysis became universal therapy. Willem Kolff did not undergo "years of confinement by the Germans during World War II"; rather, in 1943, he developed his rotating-drum artificial kidney in Kampen, the Netherlands. Belding Scribner began offering "chronic hemodialysis" in Seattle as a twice-weekly, not thrice-weekly, regimen. Eugene Schupak did not invent the concept of home hemodialysis; the credit belongs to Stanley Shaldon (Shaldon S, et al. British Medical Journal 1963;1:1717-18). Once Schupak had launched his hemodialysis program at Brooklyn Hospital in 1964, he did not perform any dialysis at the Downstate Medical Center of the State University of New York. The lack of an index in the book makes it difficult to return to a specific passage in order to validate its accuracy. Aside from such inaccuracies, however, the tale of the venture undertaken by three renal fellows who wound up as multimillionaires makes compelling reading. What is McFeeley's take-home message? Currently the chief executive officer at the Center for Policy Alternatives, a Washington, D.C., think tank that, according to its Web site, seeks "innovative solutions to the difficult challenges [that face] states and part-time legislators grappling with devolution," McFeeley urges government not to influence or dictate the manner or terms of health care delivery. "Physicians," he says, "need to reassert a command position in the healthcare delivery system." The Price of Access tells how three bold physicians met this challenge. "Build a better mousetrap" continues to be excellent advice for medical trainees who are aware of the limitations of their capacity to provide complex and expensive medical care. Had Hampers, Hager, and Schupak not founded National Medical Care, would we have the program for ESRD that now exists under Medicare? Without the leadership of the United States, would less affluent nations have attempted to create their own universal dialysis programs? Should the current ESRD program, which costs more than $19 billion annually, be restructured or dismembered, given McFeeley's charge that "having discovered a means of keeping ESRD patients alive via dialysis, the government has stopped searching for a better solution"? Despite the fact that one must answer "yes" to all of these questions, the Medicare ESRD program is a marvelous success, providing the only example of a case in which medicine has managed to replace a vital organ system for all citizens with disease due to its absence, irrespective of their political or economic station.
Eli A. Friedman, M.D.Copyright © 2002 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
