title: ESRD in the geriatric population: the crisis of managed care and the opportunity of disease management.
abstract: The geriatric population with end-stage renal disease (ESRD) is placed at risk with regards to the quality and extent of medical coverage because of the rapidly changing financial environment. Managed care organizations (MCOs) are generally for-profit companies that must focus on the bottom line. While the verbal commitment to quality care is voiced, the financial pressures on MCOs have led to a decrease in coverage of many services and outright denial for some necessary treatments. While denying services, the MCOs have also reduced payments to providers for services rendered. The coverage crisis is compounded by health maintenance organizations (HMOs) quitting Medicare because the reimbursement from the Health Care Financing Administration (HCFA) is less than their costs. Because of the above issues which can potentially impact on the quality of care delivered to the ESRD geriatric population, a new approach to disease management has created the opportunity to improve total patient care to a level not yet achieved in the United States. Disease management encompasses integrated care across all disciplines. Every component of care can be tracked by a dedicated information system. Improvement in outcomes has far exceeded the U.S. Renal Data System (USRDS) benchmark performance measurements with a disease management model approach. The key to success is the health service coordinator (HSC), a senior nurse with many years of ESRD experience. This individual coordinates care across all disciplines and expedites necessary referrals. With rapid attention to patient needs there has been a significant reduction in hospital admissions, hospital length of stay, and emergency room visits. Patient care will steadily improve as the disease management system matures as a consequence of understanding the patients total physical and psychosocial needs.
authors.affiliation: Department of Medicine, Nephrology Division, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts 02215, USA. tsteinma@caregroup.harvard.edu
authors.forename: Theodore I
authors.initials: TI
authors.lastname: Steinman
mesh_terms: D000368:Aged; D015897:Comorbidity; D019468:Disease Management; D006279:Health Maintenance Organizations / Q000191:economics; D006801:Humans; D007676:Kidney Failure, Chronic / Q000191:economics* / Q000628:therapy*; D008329:Managed Care Programs; D006278:Medicare / Q000191:economics; D011787:Quality of Health Care; D014481:United States