HOW TO MAKE A KILLING

A dispiriting look at the replacement of the Hippocratic oath by a PIN number that centers on the big business of kidney dialysis.

Basing his account on interviews with hundreds of constituents of the “dialysis community,” journalist Mueller, author of Extra Virginity and Crisis of Conscience, describes a health care industry that is seemingly entirely focused on profit. Most dialysis takes place at clinics where a premium is placed on getting patients in and out quickly, with the withdrawal and reinsertion of blood occurring more rapidly than the body can comfortably accommodate—even though in many instances, “when administered this way, dialysis may shorten patients’ lives by stripping off bodily fluids too fast, triggering sudden drops in blood pressure that can damage the heart, brain, gut, and lungs and lead to stroke, congestive heart failure, and cardiac arrest.” If you complain, you’re likely to be denied care—and, worse, far too many nephrologists are disinclined to fight on behalf of their patients. One nephrologist recounts that a colleague told her he had developed “techniques for goading undesirable patients into acting out, in order to eject them from his facility.” Most of these patients are insured by Medicare or Medicaid, a system that pays less than private insurance. Against the American system of “bazooka dialysis,” most advanced countries use a slower, more frequent program of dialysis. Furthermore, many of them place the locus of dialysis at home, with patients self-administering their care, a method that the American medical system lobbied hard to discourage. Some American physicians are bucking the system, Mueller writes, and the Trump administration issued an executive order demanding improved care—likely only because, Mueller ventures, Health and Human Services Secretary Alex Azar’s father “had been on dialysis for several years.” Even so, the system remains a mess, and bad actors are seldom punished.

An indignant, urgent indictment of the for-profit American way of medical care.