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