Why do we spend 6% of healthcare dollars on renal dialysis—but only 4% on primary care?

Both renal dialysis and primary care provide critical services, but the magnitude of their benefits is vastly different. Dialysis serves a relatively small population—many of whom are frail elderly patients, for whom the intervention may offer limited or even futile benefit. By contrast, primary care serves the entire population and is well-documented to improve quality of care while reducing overall healthcare spending.

This disparity in funding is both irrational and costly. Why does it persist?

The problem lies in our healthcare payment system. Fee-For-Service (FFS) payment, combined with diagnosis-based coding, rewards procedure-intensive services like dialysis while undervaluing cognitive, relationship-based services like primary care. As a result, funding for primary care has declined for decades, even as the costs for dialysis have grown exponentially.

We now face a serious crisis. More than 25% of Americans have poor access to primary care. Even more troubling is the rapid decline in the number of physicians choosing to enter the field. This shortage is worsening just as our aging population creates even greater demand for primary care services.

To reverse this trend, we need swift, targeted health policy reform. Two straightforward changes would have an immediate impact:

1. Require a palliative care consultation before starting dialysis.This ensures patients and families fully understand the risks, burdens, and alternatives—particularly in cases where dialysis may not improve quality of life.

2. Eliminate Fee-For-Service payment for primary care and shift to salaried compensation.This would allow primary care providers to focus on long-term patient health, prevention, and care coordination—without being penalized for taking time with patients.

Both changes would encourage more thoughtful use of dialysis and provide the support primary care needs to thrive. Without such reforms, we risk further weakening the foundation of our healthcare system.

For more on how these solutions can be implemented, visit:www.thejourneys-end.org

Insurance guidelines are not clinical guidelines—and it’s time to challenge that legally

The guidelines insurers use to deny claims are fundamentally different from those developed by clinical specialty societies. This discrepancy has serious consequences for both patients and providers—and it may be time to challenge it in court.

In “DRG Downgrades: The Clash of Medical Standards and Insurance Guidelines,” Dr. Poonacha and Lea Chamoun highlight how insurers use vague, self-serving criteria that diverge from evidence-based clinical standards.

Consider these excerpts:

• “Clinical practice guidelines are developed through a systematic process to ensure they are evidence-based… Typically, a panel of experts convenes to create these guidelines… Each author discloses any conflicts of interest… the development process is explicitly outlined… including the level of evidence for each recommendation.”

• “In contrast, the process of health insurance guideline development is often less transparent. It is frequently unclear how these guidelines are formulated, who is involved, and whether conflicts of interest exist… The divergence between insurance-driven criteria and clinical standards, such as those from CMS, leads to frequent denials of coverage… Insurance guidelines are only for specific diagnoses, not the full spectrum of health issues… This discrepancy emphasizes the need to bridge the gap between insurance guidelines and clinical standards.”

This issue extends beyond DRG downgrades and affects the entire fee-for-service system. Insurers routinely apply their own guidelines to deny payment and coverage. Giving insurers this unchecked power presents a blatant conflict of interest.

Why should an insurer—far removed from the clinical encounter—have the final say over a treating provider’s decisions?

While the authors call for “harmonizing” guidelines, a better solution is to establish independent clinical panels to review denials. The burden of proof should be on the insurer—not the provider. Clinicians, with their training and patient knowledge, should be presumed correct. Insurers should have to justify denial of care before a neutral panel.This would restore fairness and likely reduce inappropriate denials. This is not just a policy concern—it’s a legal and ethical one. Skilled attorneys should challenge the insurer’s unchecked authority. The time for reform is now.

We need to implement solutions now to avert a healthcare crisis

Dr. Pearl’s recent post predicting a “massive healthcare crisis” is right on point. He offers compelling evidence of the crisis’s likelihood and wisely acknowledges that no one knows how our society will ultimately respond. He outlines three plausible scenarios:

• Private equity–driven cost cutting

• Generative AI transformation

• Crisis-induced disruption

These are all credible possibilities. I would add two important considerations:

• The longer we delay implementing meaningful solutions, the more drastic and painful those solutions will become. We need urgent, realistic action. Slashing Medicaid coverage does not address the root problem. Instead, we must reform how we pay providers.

• Our current coding-based payment model undermines the value of cognitive services—primary care, mental health, palliative care, and gerontology. This system not only weakens these essential services but also wastes money. We should be allocating 15–20% of healthcare dollars to these core areas, not less than 5%.

Viable solutions exist - we just need the courage to implement them. For more information on these ideas, visit www.the journeys-end.org.