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PHYSICIANS' VIEWS OF THE 3
END-STAGE RENAL DISEASE PROGRAM I
presented by 4'
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Nancy Louise Buffenbarger
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A DOUBLE-30630 SWORD:
‘ VIEWS OF THE END-STAGE RENAL DISEASE PROGRAM

Vohmm I

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Nancy Louise Buffenbarger
A DISSERTATION
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Depagtnent of Sociology

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ABSTRACT
A DOUBLE-EDGED SWORD:
PHYSICIANS' VIEWS OF THE END-STAGE RENAL DISEASE PROGRAM
by

Nancy Louise Buffenbarger

Within the past thirty years, renal dialysis and
renal transplantation have emerged as feasible therapies
for the treatment of chronic renal failure. While not
prohibitively expensive, these technologies were neither
readily accessible to, nor affordable by, all the people
whose lives could have been prolonged by their use. In
1972, in the context of extensive media coverage, and in
response to lobbying by such groups as The National
Kidney Foundation, Congress adopted PL92-603 to cover
most of the costs of dialysis and transplantation for
people suffering from end-stage renal disease.

Heralded by some observers as an experiment in
national health care, the federal government's renal
disease program differed fundamentally from the public
health care systems in other industrialized nations; for
although it was publicly funded, it operated mainly
through private insurers and private providers. Thus,
the renal disease program was only a quasi-public

program, offering few challenges to the dominance of

renal care by medical professionals.

This study investigates the attitudes of renal
physicians in one state about issues of professional
control of the renal program and the quality of the
resulting program. Longitudinal surveys of renal
physicians in the state were conducted in 1980 and 1987.
Both forced-choice and open-ended questions were used in
the survey instrument. In addition, renal physicians in
leadership roles in the state's renal disease program
and officials of state and private agencies involved in
the end-stage renal disease program were interviewed.
The chi-square technique was used to compare the effects
of demographic characteristics and the structure of
medical practice on renal physicians' attitudes about
renal policy. These characteristics are not strongly
associated with physicians' attitudes on renal policy.

In conclusion, this study challenges the assumption
that physicians' opinions about government intervention
in health care are influenced primarily by physicians'
personal characteristics or by the characteristics of
their medical practice settings. This study focuses on
other factors that seem to influence physicians'
responses to emerging medical policy issues. Both the
nature of chronic renal disease treatment and the
history of chronic renal disease policy-making in the
state are viewed as important influences on renal

physicians' policy attitudes.

This dissertation is dedicated to my mother,
Agnes L. Buffenbarger
and to the memory of my father,
William A. Buffenbarger.

ii

ACKNOWLEDGEMENTS

My advisor, Don Olmsted, read my work thoughtfully
and has been a congenial mentor. Elianne Riska first
interested me in medical sociology. Nan Johnson, Ann
Olmsted, Bill Ewens, Bo Anderson, and the late John
Gullahorn assisted me in many ways.

Michigan Health Care Education and Research
Foundation, Inc., supported this research with a grant.
Those who helped with financial assistance or work are
my family, the Sociology Department at Michigan State,
Myron Magen, and Larry Reynolds and the Sociology
Department at Central Michigan University.

The friendliness of other graduate students has
lightened difficult moments. My thanks especially to
Sue Wen Lean and Alex Chang for their friendship and
practical assistance. Delores Wunder, Gordon Robinson,
Mike Indergaard, and Mike Cushion have cheered and
supported me with both academic discussions and the easy
chat of friends. My family's love, understanding, and
patience has enabled me to persevere and to finish this

work.

 

I

TABLE OF CONTENTS

Page

List of TableSOIOOIl...OOOOOIOOOIOOOI.OOOOIOOIOOOIOII
Chapter

1. Introduction..................................
Adoption of the End-stage Renal Disease
Program in the United States.................
Regionalization of the End-stage Renal
Disease Program...................... ........
The Regional Program Before 1973.............
Conclusions..................................

2. Theoretical Framework.........................
Studies of Physicians' Attitudes.............
Conclusions. ..... ............................

3. The Popular Press and Renal Policy............
The Era of Expansion.........................
Inventor/Pioneer Heroes......................
Progress Through Technology..................
Transplant...................................
Objective Benefits...........................
Subjective Benefits..........................
Policy: Issues of Equity.....................
Conclusions..................................

4. The Renal Disease Program in the United
States.......... ... .. .. .. ............
Explanations of Renal Physicians' Therapy
Choices.......... . . . ............
Lack of a Statistical Data Base for Policy
Decisions....................................

5. Research Methodology..........................

V

1

4

9
16

19
32
41

43
43
46
48
52
55
57
61
68

86

94

ConclusionSIoeeone.Iocone.one-eooeeoeoooee-oollo

iv

6. Issues of Physician Autonomy..................111
Threats to Physician Autonomy................111
Cost Containment Policy......................125
Physicians' Attitudes About Quality of Care..138
Conclusions..................................153

7. Correlates of Physician Attitudes.............157

8. conclusionSOOIOQOOIOOIO.........-0.0.0.0000000195
Policy Implications..........................211

Appendix A. The Popular Press....................219
Appendix B. Questionnaires......... ..... .........224
Appendix C. Summary of Chi-Square Results........229
Appendix D. Letters to Physicians................283

BibliograthOCOOO......I.0.........OOIOOIOOCOOOCOO285

 

LIST OF TABLES

Page

Table 5.1. Characteristics of physicians responding
to survey................. ...... ..... ........ ....... 104

Table 6.1. Outside agencies place important limits
on physician autonomy, 1987....... ........... ....... 113

Table 6.2. Agreement that the medical profession
should plan the ESRD program, 1980.................. 116

Table 6.3. The medical profession should administer
the ESRD program, 1980.............................. 117

Table 6.4. Physicians' agreement that it is
important that the government regulate the ESRD
program...‘I.........OIIOOOOIIOOIQIOOIOIOCODOOOOOOIO 117

Table 6.5. Renal physicians' evaluation of their
influence on renal policy........................... 119

Table 6.6. The degree of power Network Coordinating
Council should have, 1980.......................... 120

Table 6.7. Consumers should have more voice in renal
care policy000000000000............OOOOOIOOOOOIOOCIO 121

Table 6.8. Who presently has the most influence on
the treatment decision.............................. 123

Table 6.9. What the patient's role in the treatment
decision Shouldbe....00............OIOOOOOOOIOIIII. 123

Table 6.10. Type of renal physician and degree of
influence each should have on treatment decision,

19800.once-ooeeoecoeoeoeoeeeeeeeeeocooeooeoeeoeeoeoe 124

vi

Table 6.11. Physicians' opinions about whether
qualified physicians should be able to enter renal
care, regardless of need for services...... ........ . 128

Table 6.12. Renal transplantation should be
conducted only in a few transplant centers.......... 130

Table 6.13. Physicians agreeing that capitation
payment favors use of named treatment modality,

1987...noseones-oceans...eeeeooeoeoecoeeoccooeeoeo-e 133

Table 6.14. Physicians' approval of limitations
to eligibility for ESRD care........................ 135

Table 6.15. Physicians' views on circumstances
warranting restriction of ESRD benefits............. 136

Table 6.16 Knowledge and research in the United
States compared to other Western industrialized
nations............................................. 139

Table 6.17. Agreement that renal patients are
referred in a timely manner..... ................. ... 140

Table 6.18. Less government involvement in renal
disease would improve service delivery.............. 141

Table 6.19. The supply of ESRD services is
sufficient to guarantee that patients will receive
adequate medical care............................... 142

Table 6.20. The effect of capitation payment on
services to patients, 1987.......................... 143

Table 6.21. Effect of proprietary corporations on
services to patients, 1987.......................... 144

Table 6.22. Physicians favoring more use of the
named treatment modality............................ 145

Table 6.23. Effects of capitation on quality of
treatment modality mix, 1987........................ 147

Table 6.24. The ESRD program is a good model for
other catastrophic disease programs................. 148

Table 6.25. Physicians' positive comments about end-
stage renal disease care in the state............... 149

Table 6.26. Physicians' negative comments about end-
stage renal disease care in the state............... 149

vii

Table 7.1. Physicians' self-identified politics
and medical policy attitudes, 1980.................. 160

Table 7.2. Significant relationships between
medical education and dependent variables........... 162

Table 7.3. Significant relationships between
medical specialty and dependent variables........... 164

Table 7.4. Relationships between physicians'
attending professional meetings and dependent
variableSOCIOO....Q.II.IOI.........-.....IIIOOOIOIO. 169

Table 7.5. Memberships and dependent variable
relationships .................... ..... ............. 172

Table 7.6. Significant relationships between years
the of practice and dependent variables............. 175

Table 7.7. Significant relationship between
physician's age and dependent variable.............. 176

Table 7.8. Significant relationships between
location of practice and dependent variables........ 178

Table 7.9. Significant relationships between source
of income and dependent variables................... 181

Table 7.10. Relationship between percentage of
practice time physician spends in profit-making
setting and dependent variable...................... 183

Table 7.11. Significant relationship between medical
setting of practice and dependent variables......... 184

Table 7.12. Relationships between the organization
of practice and dependent variables................. 186

Table 7.13. Significant relationships between
physician's changing practice setting between
1982 and 1987 and dependent variables............... 188

Table 7.14. Changes toward "liberal" stance in
renal physician attitudes on issues related to
nationalization of control of the ESRD program...... 192

Table A.1. Popular press reports on potential for

technological improvements in dialysis and cost
savings in dialysis................................. 219

viii

Table A. 2. Popular Press reports on innovations that
reduce incidence of transplant rejection............ 220

Table A.3. Survival data on dilaysis patients in
the Popular Press................................... 220

Table A.4. Popular press reports of survival data
on patients who have received a kidney transplant... 221

Table A.5. Popular press reports on innovations
meant to increase access to dialysis care........... 223

Table C.1. Favor government involvement in ESRD

careeeeeeoeooeeeooeeon-o-oeone...oooeeeeeeo-osoeoeso 229

Table C.2. Favor government regulation of ESRD
program...00......0.00.0...0............OOOOOICOO... 231

Table C.3. Qualified physicians should be free to
establish practice without CON...................... 233

Table C.4. Transplant facilities should be
regionalized........................................ 235

Table C.5. Favor limits to End-stage renal disease

care-......o.......o.......c.......-....--...u.....o 237

Table C.6. Government model is good for other
catastrophic disease programs....................... 239

Table c.7. Favor increased consumer involvement in
ESRD policy making.................................. 241

Table C.8 Renal physicians are influential in
setting renal policy................................ 243

Table C.9. Age should limit eligibility for ESRD

careeooeoeoeeoone.oooeeeon...oooeoe-ooeoooooo-eeeeoe 245

Table C.10. Government limits renal physician
autonomyIOCCCCIOIOIIII......OOOOOOOOOOO......0000... 247

Table C.11. Favor limits to ESRD care based on
other illnesseSOII.......OOOICOIOOO......OIOOODIIOOO 249

Table C.12. Large corporations limit physicians'
autonomYOOOOII.IIO.........OIOOOIOCOOOIOOOIOC0...... 251

Table C.13. Capitation affects selection of
treatment modality.................................. 253

ix

Table C.14. Medical professionals should plan ESRD
program................. ...... . ......... ............

Table C.15. Medical professionals should administer
the ESRD program ........... . ......... .... ...........

Table C.16. Surgeon should have more influence on
therapy selection.............................. .....

Table C.17. Nephrologist should have more influence
in therapy selection................................

Table C.18. Large corporations have positive impact
on patient care... ....... ...........................

Table C.19. Should use more transplantation........

Table C.20. ESRD network should have more influence
in settingpoliCYOIIIOIOIIO....OIOIOOOOOOOOOOIIOOII.

Table C.21. Nephrologist has most influence on
treatment decision..................................

Table C.22. Patient should have more influence in
therapy selectionIOIOOOII...IOIOICIOOOOOIOOOCIOO....

Table C.23. Believe supply of ESRD care is
adequateOQOOOOOC.00....0..........IOODOOOOIOUIOOOIOI

Table C.24. Patients are referred to specialists
Soon enough.........OOOIIOOIOOOOIOO......OIIOIOOIQOO

Table C.25. Capitation has positive effect on
service to patients.................................

Table C.26. ESRD knowledge in the U.S. is superior
to that abroadOIIIIICOCO-0..........OOOCIOOOOOOI....

Table C.27. Favor more home hemodialysis ..........

255

257

259

261

263

265

267

269

271

273

275

277

279

281

Chapter 1
Introduction

Worsening economic conditions in the United States
have deepened the nation's sense of a crisis in health
care. The present sense of crisis in health care
springs from several social and economic trends. First,
in the United States, technology-intensive, treatment-
oriented, specialty-driven, privately administered and
financed medical care has proved costly: rates of
inflation for medical care have increased more rapidly
than has the general rate of inflation. Second,
executives in large corporations, seeking to improve
their competitiveness in international markets, are
attempting to reduce labor costs. One of their
strategies is an attempt to shift health care costs to
the workers themselves or to the government. Third, the
shift to a service economy has increased the proportion
of workers who are medically uninsured or underinsured.
The nation's high infant mortality rate, among
industrialized nations, is a constant reminder of the
lack of accessible and affordable health care in the
United States. Finally, rapid growth in the segment of
our population that is over age sixty-five has
stimulated concerns with financing both catastrophic and
chronic health care for this increasingly politically

powerful group.

Despite organized medicine's long history of
opposition to Federal provision of medical care in the
United States, the U.S. Congress enacted Public Law 92-
603, an amendment to the Medicare program, in late 1972,
providing Federal funding for most treatment costs to
patients suffering from end-stage renal disease (ESRD).
Earlier, specific population groups had received
Medicare and Medicaid; but end-stage renal disease was
the first disease entity to receive Federal subsidies.

Passage of this legislation capped federal
agencies' incremental approach to kidney disease,
according to Rettig (1979). For example, National
Institutes of Health supported research on chronic
dialysis, it supported a contract research program for
the artificial kidney in the National Institute of
Arthritis and Metabolic Diseases, and it supported a
Transplant Immunology Program in the National Institute
of Allergy and Infectious Diseases. Public Health
Service established the Kidney Disease Control Program,
to establish demonstration models of dialysis care in
different settings. Later, in 1969, supervision and
funding of the Kidney Disease Control Program was
transferred to Regional Medical Programs, with a goal of
increasing dialysis capacity. Finally, the, Veterans'
Administration established dialysis capability in thirty

of its hospitals and, at the time of the passage of PL

92-603, was dialyzing one-fourth of the nation's
patients. Rettig has argued that federal funding of
care for end-stage renal disease patients was a "logical
extension" of this cumulative process (1979:108).

After passage of P.L. 92-603, some health policy
experts were optimistic that the renal disease program
might serve as a model for Federally-funded treatment of
other catastrophic diseases or even for the kind of
national health care programs that are available in
other western industrialized nations (Simmons, 1977).
However, the mandates for the end-stage renal disease
program in the United States prescribed a program that
was in fundamental contrast to national health programs
in other nations. Specifically, the program emphasized
tertiary, highly specialized treatment rather than
primary, preventive care; it was categorical rather than
comprehensive; it was regionalized rather than
centralized; it was controlled by numerous interest
groups and agencies rather than by a single group
representing the public; most important, the program was
administered primarily through the private system of
health care, and funding was channeled through private
insurance companies, which acted as intermediaries.

Despite the differences between the end-stage
renal disease program and public health care in other

nations, the end-stage renal disease program in the

United States constitutes the nation's best-organized
attempt at national health care. Most of those who
currently urge the adoption of national health
insurance or national catastrophic disease care accept
the premise underlying the end—stage renal disease
program; that is, that it makes sense to implement a
public program through private interest groups.

When a program grants policy-making and advisory
roles to those involved in producing services, it
becomes critically important to understand their
performance as both care givers and policy-makers. As
Freidson (1975:6) has noted,

"Obviously, no policy scheme can work much

better than the actual performance of those

people who are involved in carrying it out.

Policy formation can be realistic only by

involving understanding of how the human

beings involved produce services and records

of service--the process of providing care to

others."

This case study of the development of the renal disease
program in one state is intended to illustrate the
complexities of implementing public policy through both
the public and private interest groups that have

attempted to assert control over the ESRD program.

Adoption of the End-stage
Renal Disease Program in the United States

What distinguishes end-stage renal disease from
other chronic, catastrophic diseases that could also

have been the basis of a large Federally-funded

program? End-stage renal disease involves deterioration
of kidney function and the accumulation of eventually
fatal levels of toxins. Chronicity, progressive
deterioration, and potentially fatal results are
characteristics of a number of other diseases, most of
which are underfunded in the private insurance system in
the United States. I believe it was not the unique
characteristics of end-stage renal disease, but rather a
series of social and historic contingencies that made
this disease entity the subject of a Federal program.

In the first place, only for kidney disease did two
heroic treatments--dialysis and transplantation--develop
almost simultaneously, shortly after World War II. Both
treatment modalities could bring about dramatic short-
term improvements in the patient's well-being. Some
patients who experienced these treatments showed marked
long-term gains in subjective and objective health
status as well.

As more physicians began employing dialysis and
transplantation procedures, policy for the treatment of
end-stage renal disease became standardized, at best, on
a state-wide level. More often, policy varied from one
city to the next or from one hospital to another within
a state. The costliness of treatment for kidney
failure created financial barriers to care. Public and

private insurers had no consistent policies for the

coverage of dialysis and transplantation, and many
people suffering from renal failure found that their
insurance did not cover treatment costs. Treatment
facilities were located wherever interested physicians
practiced, and thus were unevenly distributed
geographically and out of the reach of many patients.
Some local programs developed explicit social and
medical criteria for excluding patients from renal care,
based on such factors as age, presence of comorbidity,
and low likelihood of the patient's engaging in socially
valued activities after treatment.

The net effect of this anarchy of existing policy
was that for the majority of end-stage renal disease
patients, policy consisted of telling them that nothing
further could be done for their diseases. They were
treated as the victims of private misfortune, deserving
public sympathy but not public medical-care programs.
Popular media devoted unprecedented attention to the
shortage of care for patients suffering renal failure,
emphasizing the need for more dialysis facilities and
the nobility of those who donated kidneys to others.

Timing was also an important factor in choosing
end-stage renal disease to be federally-funded: The
innovations that made both kidney transplantation and
dialysis feasible clinical procedures developed during

the era of optimism and rising affluence following World

War II and were trumpeted as evidence of the superiority
of scientific, technology-based medicine. The issue of
costliness of, and access to, treatment for kidney
failure arose when government leaders' credibility was
tarnished and their priorities were under attack: Many
citizens questioned the wisdom of national leaders after
the U.S. government had conducted one unpopular "police
action" in Korea, followed by an even more unpopular war
in Viet Nam. Enactment of the end-stage renal disease
program was in part a gesture that indicated the
government could promote social welfare at home
concurrently with conducting costly warfare abroad.

In addition to technological medical developments
and timing, a powerful, politically astute interest
group, the National Kidney Foundation, formed around
renal disease and lobbied for federal assistance. Had
treatment modalities been less dramatic, had potential
gains from treatment been more modest, had politicians
been less in need of refurbished public images, had the
era been one of economic decline rather than of
affluence, or had the press ignored the existence of
treatment modalities for end-stage renal disease and the
problem of access to care, it is unlikely that interest
groups advocating Federal funding for end-stage renal

disease treatment would have succeeded.

Regionalization of the End—stage Renal Disease Program
The end-stage renal disease program in the United
States was implemented regionally, with the result that
the federal program is actually a composite of regional
programs. Federal financing made delivery of ESRD care
a potentially lucrative enterprise. To avoid costs
resulting from duplication of services, the federal
government required renal care deliverers to obtain
certificates of need. Without such certificates, large
renal care practices were not eligible for federal
reimbursement. Since the process of determining
need began at the regional level, the renal disease
program in each region is the end—product of the power
struggles between physicians for dominance over the
program. Those renal physicians already in practice in
a region had first-mover advantages in attempting to
influence renal policy in that region. Ultimately,
therefore, the social policy lessons of the end-stage
renal disease program differ in different regions of the
nation. This study will draw conclusions about only one
region. Pre-existing policy in the treatment of renal
disease in the midwestern state that is the subject of
this study set important pre-conditions on the ways in
which the federal program was implemented. Information
about the state's renal policy before 1973 was drawn

from interviews with physicians and agency officials.

agency officials.
The Regional Program Before 1973

The state that is the subject of this survey, like
all the regions comprising end—stage renal disease
networks, has a unique history of the way in which it
distributed end-stage-renal-disease care before the
legislation that enabled federal payments for care was
enacted. Because of these historic idiosyncracies,
current differences between regional renal programs can
be explored meaningfully only in the context of past
differences. Within the state that is the focus of this
study, the end-stage-renalvdisease program that has
developed, renal physicians' views about the program,
and renal physicians' attempts to direct development of
the program are best understood when the details of the
history of renal treatment in the state are known.

One of the most important features of the history
of the region being studied is that it includes nearly
all of a single state that had established a relatively
well-organized end-stage renal disease program before
federal legislation provided payment for most end-stage
renal disease care. The initiatives of several
influential individuals and interest groups brought
about the program for treating end—stage renal disease

in the state.

The Kidney Foundation

The first interest group that established a program
for treatment of end-stage renal disease in the state
was a voluntary organization, which eventually became a
chapter of the Kidney Foundation. It was founded in the
1950's by a group of influential citizens, several of
whom had relatives suffering from renal disease. In the
opinion of one nephrologist, the state's Kidney
Foundation drew considerable strength from the fact that
several of its leaders were from powerful families:

"...they had some good connections and could

collect money, so that was one of the first

strong chapters in the country."

In addition to being well-financed, Kidney
Foundation was state-wide, which gave it more unity and
impact than the city-wide chapters that arose in many
other states. The Kidney Foundation also established a
physicians' advisory board, which enhanced both the
influence and the legitimacy of the Foundation.

The Kidney Foundation made some funds directly
available for patient care: it established a system to
loan artificial kidneys to patients who could not afford
to buy them. In addition, the Kidney Foundation
established a drug bank to provide essential drugs for
needy patients.

Rather than becoming preoccupied only with direct

10

patient-care concerns and fund-raising through voluntary
agencies, the Kidney Foundation also engaged in
political activism. It convinced a state legislator to
sponsor legislation providing state funding of the costs
of home training for dialysis patients. In addition,

it mobilized organized labor, convincing the leaders of
one union to negotiate end-stage renal disease coverage
into their next benefit package. Organized labor has
been powerful in the state, and after one union had
successfully negotiated end-stage renal disease
benefits, others followed suit.

The state's major insurer had already established a
small-scale experimental precedent for paying for
dialysis: According to a pioneering nephrologist, the
medical director of the state's major health insurance
carrier had responded favorably to a request for
reimbursement for chronic dialysis:

"He was very supportive of it. This was in

November of 1966. He said he would be very

happy to fund those we had on chronic

hemodialysis, using one patient day for every

dialysis we did."

Among the Foundation's other activities were
sponsoring continuing education in renal care for
physicians, pioneering in distribution of kidney donor
cards, and eliciting cooperation of hospitals and
physicians in seeking donors of cadaveric kidneys. The

Kidney Foundation, then, was a multipurpose lay

11

"1

organization with interests in many practical aspects of
renal care.
Transplantation Group

Although not founded until 1971, a group interested
in kidney transplant was established by transplant
surgeons who wanted to rationalize acquisition,
preservation, and distribution of cadaveric kidneys
within the state, as well as to promote standardized
treatment protocols, a forum for medical review, and
support for high-quality care.

According to one transplant surgeon, the group's
membership norms were guided by principles of
inclusivity:

"Everybody belongs....somebody sponsors you,

and you get on....If you sweep the lab, you're

in....It's a--not exactly discriminating

organization from the standpoint of being

willing to accept people who express an

interest...." .

As Goffman has pointed out (1961), during surgery,
surgeons may tell jokes to reduce tensions and
resentments among those of inferior status whose
participation is necessary to the success of the
operation. In so doing, they temporarily sacrifice rank
and prestige for the sake of professional effectiveness.
The transplant surgeons' inclusive membership policy
seems to have been based on a similar approach. This
policy undoubtedly contributed to the group's relative

unity and effectiveness. According to one salaried

12

 

nephrologist, the transplantation group established
precedent for renal physicians in the state to meet
regularly to discuss and resolve renal care issues:

"...it allows for the periodic meeting of

people who are involved with transplantation

‘ to share--to build relationships so that they

can work in an advocacy-cooperative way.

From that can evolve certain policies and

procedures which are advantageous to people

throughout the state."

The transplantation group worked out a state-wide
system of sharing cadaveric kidneys: The transplant
center that performed the nephrectomy (or removed the
donor kidneys) was allowed to keep one kidney and
required to send one on to the group to be transplanted
at some other facility. Good tissue matches were
believed to be critical to the success of the
transplant; in agreeing to a system of reciprocity, a
transplant surgeon was therefore agreeing to place
survival chances for all the state's renal patients--
based on good tissue matches--above the sheer number of
transplants completed at a single center. The
transplantation group also maintained a centralized list
of patients waiting to receive transplants. Besides
tissue match, the time the patient had been waiting to
receive a kidney and the medical urgency of the
patient's condition were the criteria used to determine

the distribution of donor kidneys.

Originally the state was to be divided into two

13

 

transplantation regions, with the assumption that only
transplant surgeons in the Metropolitan area would have
ready access to cadaveric kidneys, the currency of
exchange. However, an altruistic Outstate expert in
cadaveric nephrectomy (a poorly done nephrectomy can
render the donor kidney useless) set the tone for
sharing of kidneys throughout the state, as an agency
official observed:

"...we share kidneys equally statewide. So

that was a big step. We had said in the

beginning, 'Anything [cadaveric kidneys] that

you people produce out there in Never-Never

Land you can have, but you probably can't have

what we get out of [the Metropolitan area]

since that's where the population is.‘ Well,

they fooled us by having someone out there who

was good and looking for donors and could do

it. They were outproducing [the Metropolitan

area], which was a very interesting phenomenon

they didn't expect. So that role [bickering

and distrust over sharing kidneys] was changed.

And now they are not producing as many kidneys

Outstate as they did, but they still do their

fair share, considering the difference in

population groups. And so now we share all

kidneys on a state-wide basis."

The state's Department of Public Health and the
Regional Medical Program provided start-up monies for
the transplantation group. When the group was
established, federal funding for renal transplantation
was not available. Later, the federal government's end-
stage renal disease program enabled the transplantation
group to operate as a non-profit coordinating
organization: The transplantation group arranged to pay
all costs associated with kidney harvest and delivery

14

s

 

and billed the transplant centers, which passed the
costs on to Medicare. As a counterpart to the lay-
controlled Kidney Foundation, the transplantation group
was professionally controlled. Professional norms of
universalism and expertise gradually became prevalent in
guiding transplant activities, although, as indicated in
the quotation above, the triumph of such norms did not
occur without struggle.
State-wide Data Base

Because knowledge about incidence of end-stage
renal disease in the state was necessary to further
planning and evaluation of the voluntary program, an
agency official convinced a renal physician to start a
registry of end-stage renal disease patients in the
state. According to one of the officials involved in
setting up the registry, local facilities that treated
end-stage renal disease greeted the idea of providing
information for a state-wide database with less than
uniform enthusiasm:

"...I was able to get access to the charts,

and I dug into those. Let me say at that

point that the facilities didn't really want

to do very much. They--sure--'Come on in.

Here it is. Go get it.I And it wasn't until

Medicare came into effect with the Renal

Program in July of 1973 that people started

cooperating much more. And now since they

need this data in order to apply for large,

facilities or new facilities, why they've been

quite cooperative. And we've devised quite a

simple little form that they can fill out on
their patients."

15

 

Although the registry data was, at first,
incomplete, even in its incomplete form it was believed
by both renal physicians and agency officials to be more
accurate than other data about renal care, such as that
available from Medical Information Systems.

Conclusions

Some elements of particularism and non-rationality
persisted in the state's renal treatment program:
referrals for transplant were based on acquaintance
networks rather than on logical geographic divisions in
the state. In addition, even if the transplant surgeon
did not have a good tissue match, he [there were no
female transplant surgeons in the state] was allowed to-
-but did not always--keep one kidney at his own
facility. On the whole, however, the state had fairly
standardized procedures for delivering both dialysis and
transplantation care. The resulting system of renal
care within the state was highly esteemed by many of the
people involved in administering it or delivering care
through it. In the words of one nephrologist, "I think
we've been ahead of the game all the way along and the
financial problems have been much less here."

Voluntary efforts by individuals and groups, who
were adept at mobilizing the support of other
individuals and groups, had created a relatively

systematic and unified delivery of renal care in the

16

 

state. Renal disease patients and their families could
express their concerns through the state—wide Kidney
Foundation. The Kidney Foundation's advisory board and
the transplantation group provided bases of group action
and state-wide participation for renal physicians.
Insurance carriers, the state legislature and labor
unions were supportive in increasing funding for various
aspects of treatment of renal disease, supplemented by
the Kidney Foundation. Centralized information systems
at the Kidney Foundation and the transplantation group
helped to rationalize planning for future needs and the
sharing of donor kidneys. In several respects,
particularly in its data-gathering activities and in
instituting mechanisms of renal physician cooperation,
the state's informal renal care policy was superior to
the national renal care policy that later evolved.
However, because the state's ESRD program was
essentially an accidental program, (its most
praiseworthy features developing from the actions and
good will of specific individuals, rather than as part
of a coherent public health policy) it had not been
articulated explicitly so that it could serve as a model
for implementation of the federal program. The strategy
of developing state-wide policy by processes of
interest-group activity had already generated some

friction; however, the scope of the problems that night

17

 

be generated in trying to set national policy by similar
processes became apparent only as that policy developed.
The passage of PL 92—603 altered conditions of
renal care within the state. Although payment for renal
care was assured to facilities meeting certificate-of-
need requirements, the federal government's financing of
renal care left many policy questions to be resolved
through debate in the state's End-stage Renal Disease
Network Coordinating Council. Although the Coordinating
Council gave renal physicians a means of advising the
federal government and developing local policy, the
federal ESRD program had potential to make regulations
that would limit the professional autonomy exercised by
renal physicians in the earlier state-wide program.
This study concerns the reactions of the state's renal
physicians to threats to their historic autonomy in
issues of policy-making, quality, and cost-control that
arose during the implementation of the federal end-stage

renal disease program.

18

 

Chapter 2
Theoretical Framework
This study examines the attitudes of renal
physicians about their power and professional control
over their work. If physicians in the United States
have been powerful in shaping health policy generally,
and renal policy particularly, it is important to
understand the social and cultural sources of this
power. In their explanations of physicians' dominance
of the social organization of health care, medical
sociologists have tended to analyze the claims by which
physician dominance of health care is legitimated. The
rhetoric of physicians holds that superior medical and
technical expertise qualifies the profession for autonomy
and legitimates its dominance over patients, other
medical and health care workers, and health policy in
the United States. Medical sociologists vary in the
degree to which they accept this claim and in the degree
to which they hold factors other than physician
expertise to be the actual forces shaping the social
organization and physician dominance of health care.
Talcot Parsons' functionalism informs his
examination and interpretation of the underlying forces
that shape health care. In his analysis, Parsons
accepts the claims of the medical profession, focusing

on the importance of professional values, norms, and

19

 

 

expertise in the nation's health care system. According
to Parsons, one of the functional prerequisites of any
social system is its need for individual members who are
fit to meet role obligations (1951). Therapy for those
who are not healthy is therefore essential to the
unimpaired functioning of the social system (Parsons,
1975). Provision of health care is a response to one of
society's basic needs--that of keeping its members in
good repair for role performance.

If people's incapacity to fulfill social roles
jeopardizes the survival of a society, physicians
perform an important technical function when they
restore capacities for role performance (Parsons, 1975).
If illness were entirely somatic, physicians' tasks
would be simpler. However, as society becomes
increasingly complex, people are more alienated and are
thus motivated to "retreat into ill health" via
psychosomatic complaints (Parsons, 1972:121). The
physician, in detecting and preventing malingering, is
acting not merely as a medical technician but also as an
agent of social control (Parsons, 1975).

Because of values stressing individual role
performance, members of society in the United States
find themselves evaluated on their achievements. Since
being in good health is deemed necessary to achievement,

citizens value good health and the physicians who help

20

 

them attain it (Parsons, 1972). Lay knowledge is
"notoriously fallacious" (Parsons, 1975:271) and
physicians' technical knowledge and skill are highly
developed; therefore, patients defer to the physician's
authority to regain the functional capacity that enables
them to live in harmony with basic social values. The
expertise of physicians is reliable both because it is
publicly certified (Parsons, 1975) and because it has
substituted science for superstition in health care
(Parsons, 1951).

What prevents physicians from exploiting the
confidence that both the social order and the patient
place in them? According to Parsons (1951), norms
associated with the physician's role prohibit
exploitation. First, the physician, as a professional,
is supposed to be collectivity-oriented or to be
disinterested, not self-interested, or seeking undue
profits; second, the physician's authority is limited to
a narrow field of expertise and thus is "functionally
specific"; third, the physician is supposed to be
universalistic and affectively neutral in treatment of
patients, not allowing particularistic biases to
influence objective medical decisions about the patient;
fourth, since the physician's decisions are based on
science rather than on superstition, the physician's

behavior should be characterized by rationality

21

 

 

(Parsons, 1949). Moreover, physicians are believed to
possess "intellectual and moral probity" (Parsons,
1975:267).

In summary, according to Parsons, American values
impel members of society to seek the technical services
of physicians, in order to maintain good health for
proper functioning in their roles. As agents of social
control, physicians legitimate the social order. Both
by virtue of their important social functions and by
virtue of their technical training, professional norms,
and moral character, physicians merit the unparalleled
dominance of the health care system that has been
granted to them by the public and by civil authorities
in the United States.

Eliot Freidson takes a more critical stance in his
examination of the professional dominance of American
medicine. For Freidson, political activity and
alliances are as important as cultural authority in
physicians' being granted a professional autonomy that
shapes all aspects of health care in the United States.

Freidson, like Parsons, believes science has
enhanced physicians' power because the development of
scientific knowledge and technology enabled scientific
practitioners to achieve a level of results satisfactory
to the lay public (1970b). A university education in

scientific medicine thus became an important element in

22

 

 

physicians' gaining authority over medical work (1970b).

The power of physicians is greatly enhanced,
according to Freidson, by liberals among the elite:
"those who are responsible for extending the concept of
natural disease to cover more and more types of deviance
are members of the liberal bourgeoisie" (1970az6-76).
The medical model of deviance has increased physicians'
power, for "Where illness is the ubiquitous label for
deviance in an age, the profession that is custodian of
the label is ascendant" (1970b:244). Freidson then,
like Parsons, argues that part of physicians' social
power derives from their functions as agents of social
control; however, physicians' social control functions
support the interests of the liberal bourgeoisie against
the interests of other classes.

According to Freidson, the liberal bourgeoisie
grants patronage to physicians because members of the
profession "represent or express some of the important
values of that elite" (1970b:72-3). One value of
physicians in the United States harmonious with liberal
bourgeoisie values is the belief in individualism
(1970b), especially the belief that individuals are
responsible both for avoiding illness and for seeking
appropriate help should illness occur (1970a). Another
central value of physicians is their emphasis on

independence, which reflects the individualistic,

23

entrepreneurial ideology of the bourgeoisie (1970a).
Entrepreneurial values are also congruent with the
market model of medicine. Echoing another important
value of the elite, physicians invoke ideals of freedom
to justify their own management of medical knowledge and
medical work. In the United States, physicians'
successful defense of their freedom to organize medicine
on the market model has resulted, according to Freidson,
in the control of the market by the producers, rather
than by the consumers, of health care (Freidson, 1970a).
In addition to espousing values that won patronage
from the elite, physicians have perpetuated a
reductionist view of medicine in the United States.
Weak and indifferent political authorities and selfish
taxpayers have failed to articulate the public interest
in health, enabling physicians to emphasize treatment of
individuals rather than social sources of illness
(Freidson, 1970b). To the extent that modern illness
and injury are caused by such factors as industrial
degradation of the environment, corporate neglect of
workplace safety, consumption of nicotine and alcohol,
and careless prescription of licit drugs, it is in the
interest of stockholders to preserve a reductionist view
of health. In addition, firms such as manufacturers of
sophisticated medical technologies and pharmaceuticals

are among those who profit by an approach that

24

emphasizes specialty, high-technology medicine rather
than prevention.

Representatives of physicians' professional
organizations sought recognition of their special
status--or autonomy--in interactions with officials of
the state. Autonomy, Freidson writes, is owed to the
profession's "relationship to the sovereign state from
which it is not ultimately autonomous" (1970b:24).
Claims for the privileges of autonomy are justified on
the basis of trustworthiness, which in turn is justified
on the basis of both expertise and ethics (1970b).

Freidson makes an important distinction between
"content of work" and "terms of work". Of all possible
areas of autonomous activity, "the single zone of
activity in which autonomy mug; exist in order for
professional status to exist is the content of the work
itself" (1970bz82). That is, the profession must be
"fairly free to develop its special area of knowledge
and to determine what are 'scientifically acceptable"
practices" (l970a:83). Within medicine, control of the
content of work implies the right to diagnose, prescribe
and have one's work evaluated by colleagues.

Freidson argues that physicians have expanded their
authority beyond that justified by and necessary for
their professional autonomy: They have claimed authority

over "terms of work" as well as "content of work".

25

Evidence that physicians have established authority over
terms of work is illustrated by their success at shaping
"official recognition of need for service as well as the
way that need will be organized" (Freidson, l970b:302).
Expansion of professional dominance into areas not
justified by the requirements of professionalism has
negative consequences: "...professional dominance is the
analytic key to the present inadequacy of health
services" (l970a:xi), leading to "rigid, mechanical, and
authoritarian attributes, and inadequate coordination"
(l970a:132).

Although Parsons and Freidson disagree about
physicians' disinterestedness in power, both view the role
of physician in the United States as emphasizing
autonomy and professionalism (Riska, 1985). While the
rhetoric of autonomy expounds the value of individual
freedom, the realization of professionalism is
inherently antidemocratic: "...the thrust of
professional activity is to seek to build barriers that
keep the profession and its clientele safe from those
beyond the pale while at the same time seeking
jurisdiction over all that cannot be excluded"
(Freidson, l970a:55).

Recently, physicians' autonomy and dominance in
the United States' health care system have been

threatened by two trends, described by Paul Starr in The

26

WWW Published
in an era of public concern over national health care
costs, Starr's book has been widely read and
influential. According to Starr (1982), both public and
private regulation may constrain physicians' incomes and
autonomy. In the public sector, the government has
instituted cost controls for some of its share of the
national health bill. In the private sector, health
care firms employing physicians may limit their
traditional independence for the sake of profits.

Physicians' acceptance of a market model of health
care perhaps orients them to more consciousness of
public than of private threats to their autonomy. In an
atmosphere in which cost control mechanisms have been
implemented in federal health care programs, physicians
might prefer the bureaucratic controls of corporate
medicine, promising business-like efficiency, to what
they perceive as stringent public regulation. However,
Starr argues (1982:444) that "The great illusion of
physicians and the hospital industry in the 1970s was
that liberal government was causing their troubles"

According to Starr, the failure of public efforts
to rationalize health services may, by default, relegate
planning, control, and finance of health care to private
sector conglomerates, whose major criterion for

decision-making will be the rate of return on

27

investments. Corporate thinking explicitly introduces a
new criterion, the bottom line, in assessing physicians'
activities. Although many observers have accused
physicians of having ulterior--that is, financial--
motives underlying their rhetoric about patient welfare
and professional ethics, physicians' claims to
professionalism have prevented their openly avowing such
motives. Since the concept of professionalism attaches
only to individual practitioners, health care
corporations can be unrestrained in their espousal of
the profit motive, one to which the hearts of
stockholders and would-be stockholders reverberate
sympathetically. Starr expects that physician's
autonomy will be eroded in corporate settings focused on
the balance sheet. According to Starr, conflicts
between patient-welfare criteria and "bottom-line"
criteria have been "muted by affluence," although more
austere budgeting could test the "limits of professional
autonomy in the corporate system" (1982:447).

To reduce potential conflicts with physicians,
corporations that employ them may utilize behavior
modification techniques to train physicians to "accept
management's outlook and integrate it into their
everyday work. That way they do not need to be
supervised and do not sense any loss of control"

(Starr, 1982:448). In addition, physicians who do not

28

find the corporate setting congenial can practice in
other medical settings, an option that siphons from
large-scale corporate practice the physicians most

likely to resist loss of autonomy in such a setting.

Starr's vision of physicians as a brainwashed
skilled trade sector of the corporate economy has yet
to materialize, but may be in the offing. It seems
reasonable to argue that "cost efficiency" may be the
rhetorical banner under which a different agenda--the
erosion of medical professional autonomy--will be
effected.

Currently, rather than being pawns of monopoly
capital, physicians still exhibit diversity in both
political and policy attitudes and behavior. However,
since social factors seem to be sources of much of this
diversity (Riska and Buffenbarger, 1982), predominance
of large-scale corporations in health care could bring
about Starr's scenario. Even the most individualistic
of physicians gives evidence of being "Oriented to the
social setting or environment of his work and presumed
to change his performance as the pressures of that
social environment change" (Freidson, 1975:191).

Freidson's descriptions of ideal types of physician
and practice pattern provide useful insights as to how
social and economic dynamics in the organization of

medical work may operate to influence physicians'

29

outlook on their work and their orientation to and
interpretation of autonomy. He argues that in the
United States physicians have taken one of three major
stances toward the practice of medicine. The typical
setting of the first is the solo practice, and the
typical payment mechanism is fee-for-service. The
physician behaves like a merchant in a medical market
whose foremost interest is profits. Income is
associated with status and "Problems of work tend to get
reduced to monetary issues..." (1975:54). Under these
circumstances, unless the physician is well-established
economically, he or she is predisposed to doing what the
patient-customer requests in order to retain that
patient's custom (1975). In such a setting, the
physician emphasizes market-model autonomy; to maintain
economic autonomy, the physician tries to please
patients, which could entail a loss of the physicians'
autonomy in treatment decisions or "content of work."
The second major orientation of physicians is the
bureaucratically-organized prepaid group in which the
physician is a salaried official. Status is derived
from official position within the bureaucracy, and the
aim of work is efficiency. In such a setting, rules,
rather than profits, provide guidelines for behavior
(1975). Patients appealing to rules may behave like

clients of any bureaucracy, demanding services based on

30

formal rights. Physicians unprepared to deal with these
demands may respond by adjusting their behavior to the
minimal requirements of the rules: work may become
standardized: norms, collectivized (Freidson, 1975). In
this setting, physicians gain financial independence
from patients' whims, but they may sacrifice their
autonomy to bureaucratic rules and collegial norms.

Finally, the physician may take the stance of the
craft worker (expert, professional) in a like-minded
collegium of workers, often in an academic medical
center. Status is based on demonstrated skill and
knowledge, work is viewed as inherently interesting and
rewarding, constrained primarily by the availability of
resources rather than by considerations of profits or
rules. Responsive to the professional evaluations of
colleagues, the physician as expert is likely to use
persuasion in gaining the patient's cooperation with
treatment regimens (Freidson, 1975). In this setting,
physicians have autonomy over the content of the work;
even many of the terms of work are protected by the
norms of professionalism.

In these ideal types, Freidson provides foundations
for challenging "the rather bizarre assumption that the
'long period of training' somehow creates autonomous
paragons who are what they are no matter what the

pressures under which they work" (1975:11). Once a

31

physician has chosen a medical organization in which to
practice, powerful economic and social forces generated
within that setting help to shape the physician's
attitudes, standards of work, relationships to
colleagues, and relationships to patients. Although
physicians may justify their dominance of health care in
the United States on the grounds of their expert
knowledge, their skills, and their professional code of
ethics (Freidson, l970b), threats to these core
attributes of professionalism arise from the very
organization of most medical work: Emphasis on profits
and rules rather than on inherent satisfactions of high-
quality work is, by definition, anti-professional.

Previous studies of the relationships between
sociological factors and physicians' attitudes provide
insights that may be useful in understanding renal
physicians' attitudes about their domination of the end-
stage renal disease program, the results of that
domination, and their likely reaction to either
corporate or government attempts to limit their
autonomy. These studies of physicians' attitudes tend
to support Freidson's notion that characteristics of the
medical setting are related to physicians' attitudes.

Studies of Physicians' Attitudes
Most recent studies of physicians' attitudes focus

on aspects of medical practice; for example, physicians'

32

attitudes about alcoholics in the emergency room. .Some
studies compare physicians' attitudes with those of
other groups, such as nurses, and many studies use
attitudes as independent variables. After searching
recent issues of Ingex_Megigu§ and Sggia1_§gienge§
Index, I was unable to find previous studies of renal
physicians' attitudes on policy. In addition, there are
few recent studies that relate physicians' attitudes to
characteristics of their practice settings or to
sociodemographic variables. In this section, the
available studies of physicians' attitudes about medical
policy issues and their power over them will be
reviewed.

Studies of physicians in the United States tend to
bear out the notion that they are conservative and
protective of their traditional power. Glaser (1960)
found 56% of physicians identified themselves as
Republican, with 70% preferring Eisenhower to Stevenson.
Glaser concludes that although the majority of
physicians are conservative, they are not ultra-
conservative. However, by 1964, Msdisal.Tribuns
reported that 71% of physicians favored Goldwater. In
choosing a politician with a political philosophy close
to their own, 50% of physicians picked Eisenhower, with
26% choosing Robert Taft, and 17% choosing Franklin

Roosevelt. Similarly, a study of physicians in

33

Cumberland county, Maine, found that 71.8% considered
themselves politically conservative (Pruchansky, 1983).

Physicians' conservative politics seem to be
reflected in some of their attitudes about medical work.
For example, physicians have been negative about having
nurse-midwives take over their traditional tasks
(Fottler, et al., 1978: Burash, 1975). Colombotos
(1969) found only about 37% of physicians in favor of
government participation in health care. Of the
Cumberland County, Maine, physicians surveyed by
Pruchansky (1983), 88% believed government officials are
not knowledgeable enough to regulate health care costs:
76.4% viewed certificates of need as excessive
regulation. Goldman, Cannon, and Davey (1974) found
only 25% of physicians favorable to adopting a system of
reimbursement based on capitation.

In studies less supportive of the notion of a
general conservatism among physicians, Colombotos et
al., (1975) found the majority of physicians in favor of
national health insurance and agreeable to fixed fees
under such a program. This finding could be, but is not
necessarily, indicative of physicians' liberalism on
medical policy issues: most proposals for national
health insurance leave private medical practice and
private insurance intermediaries intact. Goldman

(1974a) found physicians more medically liberal (on such

34

innovations as capitation payment) than politically
liberal. Overall, these findings suggest that
physicians are not as reactionary as is often indicated
in the literature on their attitudes.

Other studies examine the relationship between
physicians' political and medical attitudes. Goldman
found self-described political philosophy (from far_lefit
to fiaz_;ign§ to be important in predicting physicians'
attitudes about political issues in medicine (1974a).
Colombotos (1968) found physicians whose politics were
liberal more in favor of Medicare than politically
conservative physicians. Colombotos et al., (1975)
found physicians who were political liberals more likely
to favor national health insurance than physicians who
were political conservatives. Pruchansky (1983) found
political liberalism positively related to favorableness
to certificate-of-need legislation. In addition to
seeking links between political and medical attitudes,
researchers have turned to physicians' socialization and
characteristics of the medical practice setting as well
as physicians' sociodemographic characteristics to
explain variations in their attitudes.

Location of Practice

In a survey of 1314 New York State physicians,

Colombotos (1968) found metropolitan physicians more in

support of Medicare (48%) than suburban (34%) or upstate

35

(20%) physicians.
Type of Income

Lipset and Schwartz (1966) found effects of type of
income on physicians' attitudes both in the United
States and in Britain. In the U.S., they found that
physicians in private practice were more likely to be
Republican than those who are salaried. In Britain,
before establishment of a national health service, these.
researchers found that government and public--that is,
salarieQ--physicians were more favorable to state
medical care than physicians in private practice.
Babbie (1970) found that favorableness to national
health insurance was negatively related to the number of
private patients a physician treated. Strickland (1972)
found that physicians in group practice who were
salaried were more favorable to national health
insurance than physicians in group practice who were
paid on a fee-for-service basis (79% and 42%
respectively). Colombotos et al,. (1975) found that the
physicians' likelihood of favoring national health
insurance increased as the percent of their income
derived from salary increased.
Setting of Medical Practice

Strickland (1972) found physicians in hospital-
based practice were more favorable to national health

insurance than were office-based physicians (63% and 42%

36

respectively). Colombotos et al., (1975) also found
hospital-based practitioners and nonpractitioners to be
more liberal in their attitudes to National Health
Insurance (77% and 72% respectively) than were office-
based practitioners (49%).
Organization of Practice

Medical school faculty (72%) and multi-specialty
group members (74%) have been found to be liberal on
medical policy matters compared to 41% of members of
single-specialty groups and 32% of solo practitioners
(Goldman, 1974a). These differences may arise from
differences between groups of physicians in various
practice organizations: Goldman and Ebbert (1973) found
medical school faculty the most politically liberal
(71%), followed by physicians in multi-specialty groups
(42%), single-specialty groups (25%), and solo practice
(16%). Mechanic found doctors in group practice to be
more favorable than nongroup doctors to such innovations
as Medicaid, National Health Insurance, community health
centers and prepayment mechanisms (1974). Pruchansky
(1983), however, found that solo practitioners were less
opposed than group practitioners to certificate—of-need
legislation. He argued that group physicians were more
likely than solo practitioners to wish to purchase the
expensive equipment that was to be regulated by

certificate of need. If his explanation is correct,

37

specific self-interest seems more important than general
political orientation in explaining physicians'
attitudes on specific issues in medical policy.
Medical Specialty

Colombotos (1968) found surgeons in New York State
the specialty least supportive of Medicare. Goldman
and Ebbert (1973) found physicians in medicine more
liberal on medical issues than were surgeons (67% and
38% respectively). Mechanic (1974) found specialists
more receptive than general practitioners to innovations
in the delivery of medical care. Colombotos et al.,
(1975) found surgeons less favorable to national health
insurance than other medical specialists (41% and 61%
respectively). They also found specialists more in
favor of National Health Insurance than were general
practitioners and family practitioners (1975). These
differences, too, may be related to physicians' general
political liberalism: for example, Goldman and Ebbert
(1973) found that surgeons are the specialists who are
least likely to be politically liberal. Goldman (1974a)
concluded that physicians' politics may be the best
predictor of their medical philosophy. However, it
seems likely, from the results of other studies cited
here, that political attitudes, as well as attitudes on
medical issues, may be influenced not only by specific

vested interests deriving from the practice setting but

38

also by ongoing socialization in the practice setting.
Medical Education

Herman found that medical students became more
conservative during medical school, with seniors "moving
toward traditional physician attitudes" (1984:204). A
study reported in gall;grnia_flegigine (1969) also found
50% of residents, 33% of seniors and 25% of freshmen
opposed to government intervention in medical practice,
supporting the notion that physicians become more
conservative on macropolitical issues as they are
socialized in medical school and residency.

Although medical education appears to increase
physicians' conservatism on macropolitical issues,
it seems to socialize them to more liberal attitudes on
micropolitical issues: Leserman (1980) found that during
medical school, physicians became more egalitarian in
their beliefs about physician-patient relationships, but
they became more conservative on the issue of government
intervention in medicine.

Research by Lavin, Haug, Belgrave, and Breslau
(1987) supports the idea that medical school training
influences young physicians' opinions. During medical
school, physicians' attitudes became more egalitarian on
micropolitical issues of physicians' authority and
patients' rights, moving closer to the beliefs of the

faculty about these issues.

39

Country of Medical Education

In a national survey of physicians, Colombotos et
al., (1975) found that physicians educated abroad were
more favorable to national health insurance than were
physicians educated in the United States (72% and 54%
respectively). Colombotos et al., (1977) found that
physicians educated abroad were more liberal than
graduates of United States medical schools on issues of
national health insurance and the role of government in
health care. Although more liberal than their U.S.-
educated counterparts, senior physicians educated abroad
were more conservative than housestaff who received
medical educations abroad. The researchers attribute
their findings largely to socialization effects, arguing
that foreign-educated physicians who migrate, while more
liberal than those educated in the U.S., are probably
more conservative than those remaining in their country
of origin: with increasing time in the United States,
they become even more conservative as a result of
exposure to the more conservative values of physicians
in the U. 8. (1977:607).
Normative Climate

Nathanson and Becker (1981) have suggested that the
normative climate prevailing among a group of physicians

in a practice setting sometimes affects the behavior of

40

physicians. They found that the majority of
conservative obstetricians offered abortions when they
practiced in settings where the normative climate
favored abortion but tended not to offer abortion where
prevailing norms opposed it.
Ethos

Several researchers note the probable effects of
the general culture or mentality on physicians'
attitudes. In a longitudinal study conducted in 1972
and in 1977, Glasser, Frate, and Johnson found that
physicians had become more conservative on a variety of
issues, such as support of national health insurance and
approval of Comprehensive Health Planning as the agency
that should coordinate health care facilities in an
area. These researchers argue that such changes in
physicians' attitudes probably "offer a reflection of
societal changes in general" (1980:191). Coe, Pepper,
and Mattis also note a decline in liberal responses of
physicians and argue that their liberalism from 1970 to
1972 was a "temporary phenomenon [that] was a reflection
of social and political unrest of a specific and
limited period of time..." (1977:96).

Conclusions

Studies that indicate the effects of time in

medical school, country of medical education and

professional norms of peers on physicians' attitudes

41

tend to bear out Freidson's notions that physicians are
responsive to the social setting provided by peers and
colleagues: their socialization is not completed with
medical school but is ongoing and apparently responsive
to changes in the ethos of the larger society. Other
studies tend to bear out Freidson's notions on the
important influence of various elements of the medical
practice setting on physicians' attitudes. Many of
these studies have suggested the important effects that
the characteristics of the social setting of medical
practice have on the behavior of physicians, possibly
through the influence of ongoing professional
socialization. However, these studies do not focus on
attitudes of renal physicians. In order to sketch a
picture of the prevailing attitude to renal care in the
larger society that may have influenced renal
physicians' attitudes, popular press treatment of issues

in renal care will be examined. -

42

Chapter 3
The Popular Press and Renal Policy

Examination of popular press reporting on issues in
renal care elucidates the specific popular values that
supported government intervention in renal disease and
the social conditions that increased renal physicians'
receptiveness to federal intervention in the treatment
of renal failure.

Of the United States' medical policy following
World War II, Paul Starr (1982:338) has written:
"The first phase of postwar policy, favoring
growth without redistribution, gave way by the
mid-1960s to policies that tried to improve
distribution yet without any fundamental
reorganization of the system. Still later, in
the 19705, public policy, after pursuing
growth and redistribution without
reorganization, accepted the need for
reorganization to step growth.
The succession of objectives in medical
policy--expansion, equity, cost containment--
paralleled the more general succession of
concerns in postwar social policy."

The first and second policy phases described by
Starr will be used as an analytic framework to review
popular press literature on renal disease research,
innovation, and policy in the United States since 1950.

The Era of Expansion

Both hemodialysis and renal transplantation had

been subjects of sporadic medical experimentation since

the early part of the twentieth century. In reporting

on that early era, the press focus was 1) emphasis on

43

the centrality of technology and technique in health
care and 2) celebration of medical research and
researchers. Merrill (1961:58) reports, for example,
that

"The first successful application of an

artificial membrane to living animals was made

by John J. Abel, L.G. Rountree and B. B.

Turner of Johns Hopkins University in

1913. They passed the blood of dogs through a

branching network of collodion tubes immersed

in a bath and showed that toxic amounts of

aspirin could be rinsed out of the blood....

They did not have modern anticoagulants, so

Abel turned, ingeniously but laboriously, to

the leech, which was known to secrete an

anticlotting factor called hirudin as

it sucked blood. The Johns Hopkins workers

ground up the heads of thousands of leeches to

get enough hirudin to keep the dogs' blood

from clotting tubing. As an experiment Abel's

attempt was eminently successful...."

In this description is a precis of themes
frequently evoked about technologies used to treat end-
stage renal disease: farsighted and creative individuals
working with the often homely materials at hand perform
seeming miracles of innovation, forging new frontiers of
medical knowledge. In these tales of the adventures of
modern medical knights, the quest for the Holy Grail has
been reduced to the search for medical knowledge, and
the protagonist finds romance in pursuing mysterious
techniques and technologies. Such romanticization of
the work of medical researchers both reflects and
enhances the prestige of medical research and creates an

aura of glamour that surrounds even medical practice

44

(Olmsted, 1990).

Dialysis and transplantation were only two of a
variety of techniques publicized for treatment of kidney
failure. Others included 1) use of exchange resins to
absorb body toxins (Seien;ifiie_eme;ieep, 1952); 2) cross
transfusion, in which the blood of the sick person was
passed through the circulatory system of a healthy donor
of the same blood group and then returned to the sick
person (Salisbury, 1954): 3) sound waves to clean the
blood (electro-osmosis) and 4) use of the enzyme urease
to break down urea (Robbins and Robbins, 1967: Sgigngg
Neye, 1968).

Shortly after World War II research into both
hemodialysis and transplantation brought them to the
stage that they became technically viable treatments for
a few patients with renal failure. The press
underscored the immediate practical value and long-term
research implications of the successful use of
hemodialysis in treatment of renal failure (Time,
1961:74):

"...it shows that an artificial organ can

substitute for the natural one for long

periods. It will help researchers to find out

what the deadly metabolic poisons are and

thus, perhaps, point the way to cheaper,

safer and less cumbersome ways of treating all

forms of kidney disease."

In addition, hemodialysis research is alleged to

have "pure science" implications beyond the narrower

45

scope involved in treating and understanding renal
disease (Wolf, 1952: 193, 198):

"...there is no discernible limit to the

novelty, wealth, and importance of

hemodialytic explorations."

Inventor/Pioneer Heroes

Reflecting a boundless faith in technological
solutions, the press emphasized progress in treatment
of renal disease, with both innovators and their
innovative techniques and technologies as essential
elements of that progress. Often the innovators in
dialysis technology were depicted as American culture
heroes--idiosyncratic, outspoken men whose approach to
medicine reflects the ideals of Yankee ingenuity and
thrift. As described by the press, they combined common
sense, a sometimes crusty individualism and humanitarian
motivations in their work. For example, "Head and
shoulders above other kidney makers is tall, tart Willem
Johan Kolff," (Time, 1959:32). He was viewed as having
"cut the Gordion knot" (Wolf, 1959:193). Dr. Kolff's'
culture hero status was enhanced by his having pioneered
workable dialysis in the Netherlands under adverse
circumstances (Salisbury, 1954:26):

"during the German occupation when the plastic

materials, stainless steels and other items we

now take for granted were not available to

him. In spite of these handicaps, he was able

to perfect his machine and to use it with

encouraging results in treating sick people."

Because Kolff's first dialyzer required surgical

46

access to veins, problems in establishing surgical
access limited the number of times dialysis could be
performed on a patient: that is, Kolff's invention
enabled only short-term dialysis and was suitable for
acute, but not for chronic, cases of renal failure.

A second inventor-physician is credited with
making dialysis technology available to sufferers of
chronic end-stage renal disease. As reported in the
press, Belding Scribner's invention was equal in the
drama surrounding its inception to Kolff's. After
mistaking a case of chronic renal disease for acute, Dr.
Scribner succeeded in using hemodialysis to successfully
reverse the symptoms of uremia, only to lose the patient
a second time when it became apparent that the disease
was chronic. Shortly afterward, in January of 1960, as
recalled by Dr. Scribner (1971:21):

"'...I woke up with the idea in the middle of

the night. Actually, I wake up like that

quite often. I do my best thinking at four

a.m.' That may be understating it, for that

particular interruption evolved into a

revolutionary medical-surgical treatment."

This revolutionary treatment involved permanently
implanted cannulas, one in an artery and one in a vein,
connected by a shunt, which would permit repeated access
to dialysis sites. Besides calling attention to the
fact that, like Kolff, Scribner employed simple
materials, the following report also contrasts the

creative, idealistic scientist with the rigid hospital

47

bureaucrat (Heinz, 1971:29):

"The original apparatus with which he and his
associates were working was so crude that one
of its components was a Sears Roebuck deep
freeze mounted on wheels and wrapped in
insulation and a blanket. At one time,

in an attempt to get enough negative pressure
to apply a vacuum to the dialysate compartment
of the machine, they hung a rubber hose out of
a fifth floor window, but that experiment was
terminated after a week by the hospital
administrator to preserve the ornamental
shrubbery below."

The combination of necessity, pragmatism and
idealism motivating pioneering research is similarly
underscored in reports on a third inventor-physician,
Dr. Eli Friedman (Time, 1976:60):

"[A patient's] unexpected freedom was the
result of a remarkable new device: a portable
mechanical kidney so compact it is built into
a small metal valise. 'The idea came to me out
of simple frustration,‘ says Dr. Eli A.
Friedman, inventor of the suitcase kidney.
Friedman, director of the renal diseases
section at New York's Downstate Medical Center
had planned to take 25 kidney patients on a
European holiday in 1974, dialyzing en route.
But at the last minute, medical authorities in
Copenhagen concluded that they did not have
enough dialysis machines to handle so many
additional patients. Forced to cancel the
trip, Friedman resolved to build a dialysis
machine that kidney patients could carry on
their travels and operate by themselves.
...Friedman and his engineering collaborator,
James Hutchisson decided on a 5-gal. plastic
container customarily used by campers and
yachtsmen to carry water."

Progress Through Technology
Despite the fact that early dialysis machines were
employed only in cases of acute renal failure, press
reports extolled acute dialysis for its usefulness in

48

reversing acute kidney failure following a wide variety
of traumas, from heatstroke to crushing injuries to
malaria. In addition, the artificial kidney was
utilized to complement the work of a patient's kidneys,
speeding the removal of such poisons as barbiturates,

bichloride of mercury, and carbon tetrachloride

(Andreas, 1957:108: Scienss_nsus_Lsttsr 1952:178 and
Seienee_flege_§e§§e;, 1953:325). A patriotic note was

sounded with the report that dialysis was effective in
treating kidneys that had stopped functioning because of
injuries incurred on the battlefields of Korea (fieieeee
News Letger, 1951:35). Dialysis was even alleged to
create "remarkable improvements" in schizophrenics
(Merrill, 1961:62). Although the research on which the
schizophrenia claim was based was later shown to be
unsound, the reputation of dialysis as a "miracle"
technique persisted.

Reports that dialysis had proved useful in treating
medical iatrogeneses, such as post-surgical trauma,
derangement resulting from ingesting toxic doses of the
blood pressure medication, potassium thiocyanate, and
mismatched blood transfusions further exemplified the
broad applications of the new technology (Seienee_fleye
Legpep, 1951:35; 1953:21 and 1955:4). By 1951, the
artificial kidney was credited with reversing acute

kidney failure in 150 cases, thus saving 150 lives

49

(Ssiense.flsms_1stfsri 1951:35)-

The scientific breakthroughs of dialysis pioneers
lent broad support to the notion that answers to the
remaining imperfections in renal treatment depended on
similar future breakthroughs, supplemented by sound
business practices. To support these notions, the press
detailed minor advances in dialysis, describing both the
improvements in technology and social organization of
care and potential benefits of these innovations (see
Appendix Table A.1.)

According to Riska (1985), heroic, or allopathic,
medicine triumphed over a number of other medical sects
in the late nineteenth and early twentieth centuries,
both through its harmony with the prevailing
"scientistic climate" and through its political
maneuvering to eliminate competition. Allopathic
medicine is "mechanistic and reductionistic" (Riska,
1985:32), focusing on scientifically based treatment of
disease rather than on the health preservation advocated
.by most other medical sects. Generally uncritical of
the assumptions on which heroic medicine is based, early
reportage on dialysis tended to focus on and magnify the
inherent drama of the technique. The potential of the
technology is frequently stated in explicit, optimistic
terms: Reports on lives saved by dialysis during the era

of acute treatment illustrate that such optimism is

50

warranted.

In the early part of the twentieth century,
Frederick Taylor, with his principles of Scientific
Management, had encouraged engineers to organize work
to reduce sources of human variability in production.
The extent to which Taylorized thinking, which expounds
the desirability of "smart" machines compensating for
human vulnerability, had penetrated the popular
imagination is epitomized in statements like the
following (Andreas, 1957:108): A

"The artificial kidney is no longer an

experimental object. It has saved countless

lives and proved itself time and time again.

It has risen slowly from out of the mingled

fumes, test tubes, and statistics of hundreds

of laboratories, where workers whose names you

will never hear toiled quietly toward the

perfection of an idea."

In another description, genius has been transferred
from the inventor to the machine: "As early as 1912 the
U.S. pharmacologist John Abel constructed an "ingenious
machine" (Salisbury, 1954:26). The counterparts for
animistic metaphors for machines are reductionistic
metaphors for the human body as an inferior, improperly
functioning machine, and reporters write of "sending
your blood to the cleaners," (Pepeler_§e1enee_nenenly,
1951:103) and of "dialysis hotels" which serve as "human
laundromats" (Time, 1968:75). There are equally
mechanistic metaphors for transplant, with the kidney
compared to a carburetor (Time, 1960:53).

51

The kidney machine is even depicted as Christ-like
in its relationship to humanity (Andreas, 1957:108):

"Today it is there, created by medical science

through patience and ingenuity, and curiosity,

to serve the many in need, perhaps someday to

serve--and save--you."

Transplant

As in the popular press treatment of pioneering
efforts in hemodialysis, reports on early attempts at
kidney transplant focused on the heroic qualities of the
kidney transplant teams. The effect of emphasis on
their daring, teamwork, and cooperation is to dramatize
the technique and to reduce the surgeons to brilliant
but faceless heroes. They were described as a "crack
team"... [taking part in a] "historic operation" (Life,
1960:108). Such surgeries were further described as
"desperate gambles" (Galton, 1964:94), "a record of
brilliant medical accomplishment" (Se;n:§ey_£yen1ng
Beep, 1955:33), and "miracles" and a "triumph"
(Newsweek, 1959:106). Descriptions of the operating
theater heighten the drama (Hirshberg, 1955:173):

"For the next 45 minutes, the team in the

amphitheater worked on the grim jig-saw

puzzle, following the plan that had been

formulated in the previous 15 minutes."

The aura of religion is often an important part of
the writing on treatment of renal failure. In the

following example, surgeons' activities, besides being

compared to the accomplishments of classic genius, are

52

placed in the context of family prayer (TedeyL§_fle§lth,

1971:25):

"About December 20th a group of surgeons,

physicians and immunologists met in the

hospital in what was surely one of the most

dramatic confrontations in medicine. Had they

any right to take a kidney from a healthy

person...? [After describing the family's

joining hands to pray for the success of the

surgery] At that moment other hands, rubber-

gloved and of consummate artistry, were placed
upon 8.1. and Tommy. The techniques evolved

at kidney centers around the world now blended

into an orchestration as precise as a Bach

concerto."

As with dialysis, the press demonstrated faith that
technological solutions for problems in transplant would
arise, and reported frequently on newly developed
techniques or technologies that would improve survival
and quality of life for those undergoing transplants.
Between 1950 and 1988, a total of twenty-three
innovations that involved improvements in preventing
rejection of the transplanted tissue, improvements that
increased numbers of potential kidney donors, and
improvements in keeping donated kidneys viable from the
time of removal to time of reimplantation were reported
(see Appendix Table A.2).

Human Interest Stories

In addition to reports on pioneers in treatments
for renal disease and updates on technical advances in
dialysis and transplantation, the press also focused on

benefits to ordinary people who had experienced

53

transplantation or dialysis. The human-interest story,
a minidrama starring Everyman, was frequently used to
make the point about the value of both therapies. For
example, it was reported in 1957 that the artificial
kidney had saved lives in such circumstances as when,
"One dark winter might a despondent young man swallowed
a handful of sleeping pills and lay down to await death"
or when a "...young soldier whose legs were severely
torn by an enemy mortar shell" was treated (Andreas,
:1957). Among other examples of this genre are the
following, which illustrates the democratic application
of dialysis to an ordinary working man (Time, 1959:32):

"In New York City last week a longshoreman,

62, went to his medicine cabinet in the dark

seeking castor oil, pulled out the wrong

bottle and drank 2 oz. of oil of wintergreen.

[At Bellevue Hospital] Dialysis ('through

solution') took six hours, with a squad of

four physicians and specially trained

technicians in constant attendance. It saved

the longshoreman's life."

Even more dramatic, dialysis saved the life of an
innocent child who had accidentally endangered himself
by ingesting another medical miracle (Time, 1959:32):

"Smallest patient treated at New York Hospital

was a 26-lb., two-year-old boy who had

mistaken aspirin for candy. The vessels in

his arm were not big enough for cannulas, so

the doctors worked tubes from his thighs up

into the great veins entering the heart, kept

them spaced far enough apart to avoid

recirculating the same blood. After dialysis

and a night's sleep, the boy woke up well."

After Scribner's invention of the shunt, the same

54

sort of human interest stories that had appeared about
acute dialysis began to appear about patients undergoing
chronic dialysis. One of the early examples follows
(Time, 1961:74):

"Every business day but one, Ben A. gets into

'his car in a Seattle suburb and drives clear

across the city to the sporting-goods store

where he is a clerk. He puts in a normal

workday, then drives home to his wife and two

small children. What sets Ben A., 24, apart

from millions of other Americans who drive

daily to and from such jobs is that he spends

Wednesdays--a full 24 hours--in University

Hospital, hooked up to an artificial kidney.

Without that stint on the machine, he would be

dead, probably before the month is out."

Through such stories, the popular press depicted
dialysis and transplantation as potentially beneficial
to ordinary Americans. That many of those treated with
dialysis were the unwitting victims of the products c.
science merely illustrated that science can be used to
correct some of its own negative outcomes.

Objective Benefits

The theme of constant progress in dialysis and
transplantation technology was repeated in reports on
survival of patients using dialysis and transplantation
technologies. Any gain in days of life or improvement
in quality of life was reported as progress. Although
the measures of technological efficacy employed by the
popular press are relatively unrefined, the popular
press showed more concern than did the early medical

literature or government agencies in developing ways to

55

assess the value of dialysis in terms meaningful to the
public.

In general, the popular literature first emphasized
sheer numbers of deaths prevented by renal technology,
and only later became concerned with length of survival
and quality of life (see Appendix Table A.3). The
negative side-effects of dialysis were often reconciled
by contrast with the alternative: "...perhaps it is not
so difficult to live with when one realizes that without
it, death is the only alternative" (Burton, 1967:68).

A success bias also predominated in the early
transplant literature. The first transplant attempt,
from a cadaveric donor, appeared successful. However,
although the patient survived the procedure and regained
kidney funcsion, the transplanted kidney was later found
to be shrunken and useless, apparently having relieved
the remaining kidney until it could resume functioning
(Time, 1951:44-45 and fieiemee_gigee§, 1951:48-49).

Despite this setback, optimistic reports on renal
transplant continued: "Doctors are not discouraged [with
renal transplant] despite the 10-percent survival rate"
(Pepular Science, 1964:94). Six early transplants were
reported with "at least temporary success" in three of
the six (Seiemce megs LetEem, 1952:211). A
transplant patient's survival of only five months

triggered the hope that "the transplant problem is

56

 

nearing a solution" (fieiemee_2;ge§§, 1954:48-49).

Issues of length of survival under treatment and quality
of life could be sidestepped with phrases like a
"fantastic record", in reporting success of cadaveric
transplants (fieiemee_fleme_Le§;e;, 1965:39).

Nevertheless, popular press reports on survival
statistics for recipients of transplantation were not
markedly inferior in sophistication to those reported in
the early medical literature in the United States.
These reports (see Appendix Table A.4) tended to support
the idea that in medicine, progress in technology has
increasingly large payoffs for human well-being.

Subjective Benefits

Popular press descriptions of successful dialysis
and transplantation make frequent reference to patients'
transformations after treatment. In a patient suffering
acute kidney failure and treated by renal dialysis: "her
appearance had changed so within 36 hours that the
doctor caring for her had trouble recognizing her"
(Seienee_fleye_Le§§ez, 1955:4). One physician observed
(Salisbury, 1954:26):

"It is one of the most gratifying experiences

in medical practice to see the revival of a

patient who has been brought in unconscious,

twitching convulsively and vomiting

uncontrollably and who, after a run on the

artificial kidney, sits up in bed and asks for

breakfast the next morning."

Wolf (1952:197) observes that dialytic resurrection

57

restores the ability to perform gender stereotypic
roles: "...consider a woman, dialytically awakened from
what should have been her final sleep, who can
effectively, skillfully, and promptly lie about her age"
Clyde Shields, the first chronic dialysis patient,
remarking on his first dialysis, noted "...it was just
like turning on the light from darkness" (Heinz,
1971:29). Finally, one patient writes (Foster,
1976:103):

"Every day, when I am immersed in work or some

pleasurable leisure activity, I completely

forget for hours at a time that I am staying

alive on a kidney machine. And when I

remember, the realization sharpens my senses

and makes whatever I am doing more immediate,

more rewarding."

The transcendent attainment of a sense of the
eternal now, and heightened consciousness of everyday
joys, are common themes in articles about transplant
patients. To be deathly ill and to be returned to a
state of being "as normal as blueberry pie" or to
"...feel like I haven't been sick a day in my life" were
expressions used to describe experiences of transplant
patients (Nememeek, 1963:12, 55). One assistant editor
who received a transplant said (g.§. mews ang Womlg
Report, 1975:54):

"I don't know when I have been so happy in

terms of enjoying the simplest things--things

which I had taken completely for granted

before.

I sometimes laugh at myself. It's like going

through a second childhood.

58

I enjoy a drink of water. I enjoy a piece of

fruit. I enjoy the sunlight. I go into my

garden and look at the trees. I discover that

I had never really seen what a tree looked

like in all those years that I had good

health. And I enjoy the birds' singing--just

everything!"

A dancer who received a transplant reported
attainment of a Zen-like state of appreciation of
daily activity (Blank, 1973:212):

"What is important is my dancing. What is

important are the things I see and hear and

feel and do. What's important is now."

Such passages, invoking the transcendent, depict a
secular resurrection. However, the language describing
experiences of transplant recipients and donors often
involves overtly religious figures of speech. One motif
evokes the sanctity of the creation and bestowing of the
gift of life. After the first successful kidney
transplant from Ronald Herrick to his identical twin,
Richard, on December 23, 1954, physicians announced
(Serenst. 1955:174)=

"The Herrick twins have been an inspiration to
us all in their unflinching willingness to
share their lives in such a vital way. No
better example of the spirit of Christmas can
be found."

A son donating a kidney to his mother is described
as "returning the gift of life" (Harris, 1980:100).
Similarly, a daughter donating to her father titles her
article "I gave my Father the Gift of Life" (Kesselman,
1980:168). For one kidney recipient, her physician's

59

permission for her to become pregnant was "the most
wonderful thing any one ever said to me." The baby was
described as a "seeming miracle" to the "still bedazzled
parents" (Keiffer, 1969:62, 72). In an article entitled
"Our Little Girl Is a Medical Miracle," a woman writes

of herself and her husband (geeg_nemeekeepimg, 1978:62):

"...through the miracle of kidney transplants,

both of us have received a second chance at

life. And what once seemed an impossible

dream [having a baby] has come true."

For kidney donors, metaphors of Christ-like
sacrifice are employed (Montgomery, 1969:42):

"Evangelical Christians have the strongest

possible reasons for performing a service not

only with their bodies after death but also

through living donation of one of their paired

kidneys. At the very center of the biblical

message is the doctrine of suQsEigmt ien.

Christ gave himself totally and unreservedly

in our place and for our sins. The moral

consequence is inescapable."

Donation of a kidney is claimed to strengthen
family bonds, a literal and symbolic act of brotherly
love: for example, "The moral dilemma it [kidney
donation] posed is as old as the Book of Genesis: Is man
his brother's keeper?" (Igdaxls_flsalth. 1971:23). The
donation of one of an Israeli's kidneys to a PLO member
occasioned expression of a hope for political as well as
physical healing: It was described as "just enough...for
moving Arab-Israeli problems in the 805" (Delloff,
1980:246). Moreover, the employment of biblical
metaphors suggests that the physician's role is that of

60

God's agent on earth, bringing about modern-day miracles
through medical technology. The lay public can
participate in this quasi-sacramental activity by
sacrificing surplus organs to restore the miracle of
life to those in danger of losing it.

Policy: Issues of Equity

Demand for the seemingly miraculous techniques and
technologies for dealing with renal failure soon
outstripped resources for providing them. A second
phase of reportage, dealing with unavailability of renal
treatment, began to echo the phase of government policy
which Starr describes as demonstrating concern with
distribution of health care without reorganization of
the health care system.

A series of articles described the emotional crises
of those caught in the crunch between supply of and
demand for treatment of chronic kidney failure.
Estimates of the untreated ESRD population that could be
helped by dialysis ranged from 3,600 to 90,000. The
fraction of the population being helped by dialysis
compared with those needing help was estimated to range
between one tenth and one third (Heinz, 1971: Nemsweek,
1966:62).

One article, for example, focused on a single
nephritis victim and his wife's fruitless attempts to

obtain dialysis care for him. The victim was a father

61

of two, a Ph.D radiologist, who was denied hemodialysis
because of having diabetes (Robbins and Robbins, 1967).
His final request to see his sons, his three-week coma,
his wife's burying her wedding ring with him, her
breaking the news to her sons and putting away "the
'things that had made me a wife" [especially, a soup pot]
are detailed (p. 134).

The focus of these articles was on middle-class
people, no longer able to work because of their
illnesses. To relatives, friends and victims of the
disease and to the press, denial of care to such worthy
citizens constituted a bizarre world in which merit and
fairness no longer prevailed (Suczek, 1973:45). Robbins
and Robbins comment (1967:81):

"Every year 20,000 Americans find themselves

caught in the struggle and they learn...of the

impersonal judgments and strange priorities

that decide whether they are to live or die."

Equally compelling were the descriptions of the
workings of the "life-or-death" selection committee. In
Washington, home of Scribner, the developer of the shunt,
one such life-or-death committee was established. After
a medical screening to determine suitability for
treatment, the committee, consisting of local citizens,
constructed selection criteria and made selections of
those who would receive treatment. At this point,
social, not medical, factors were used to select

patients for treatment. Patients' economic and social

62

resources that would enable them to realize full
benefits from treatment, as well as their potential for
making contributions to society, were major factors
considered in the selection process (Alexander, 1962).
In the absence of selection committees, there were
"hand-wringing tales of doctors and hospital
administrators who must play God, deciding which kidney
patients to save and which to let die" (Time, 1964:42).

Dr. Kolff, dialysis pioneer, questioned national
spending priorities (Sciemee News 1966:286):

"In a world in which billions are spent for a

limited war, other billions are spent to fly

to the moon, and one billion dollars per year

for cosmetics, money cannot be found to

restore patients dying from chronic renal

failure."
Voluntaristic Solutions

The first response to the issue of access to renal
care was typical of the United States, which, having a
tradition of interest group liberalism and voluntarism,
and lacking a comprehensive public health care program,
was a natural setting for groups with a variety of
agendas.

Even before chronic dialysis was possible, the
American Heart Association supported acute renal
dialysis. Concerned, in 1959, that cardiovascular-renal
disease accounted for half of the deaths in the United
States, the American Heart Association chose to

emphasize the renal part of the triad in its annual fund

63

drive (Time, 1959:32). In 1963, The U.S. Public Health
Service spent $300,000 to expand kidney programs and in
1965 it spent $3.5 million to train staff and to help
set up new dialysis centers (Neyemeek, 1966:62).

Other organizations that made contributions to
dialysis research and care were the John A. Hartford
Foundation (Hememeek, 1970) and the National Institute
of Arthritis and Metabolic Diseases of the National
Institutes of Health (Burton, 1967:29). For a small
group of patients, estimated at 300, the access problem
was resolved when Veteran's Administration hospitals
began to provide dialysis services to eligible veterans
with kidney failure (Burton, 1967:68).

This patchwork pattern of funding only aggravated
problems of equity: access to care often depended on
state of residence, having been a veteran, and other
nonmedical criteria. Most of the press uncritically
accepted this pattern of private, public and voluntary
agency funding efforts: however, reporting of the
bureaucratic inadequacies of the program continued.

For example, even when treatment was available
through programs of state governments, the Veteran's
Administration, and private insurance companies, which
helped to defray costs, the remaining costs forced many
families onto welfare and forced them to sell homes and

cars and even to divorce in order to qualify for

64

treatment (Time, 1971:57; Suczek, 1973:46). In some
cases, it was reported, individuals had decided to
forego treatment rather than subject their families to
such privations (Suczek, 1973:49: Ngfléflgék, 1972:73).

Resolution of the problem of equality of access to
renal care was at first sought primarily in cost
reduction efforts. Many researchers continued to direct
their efforts to developing less costly technologies
(see Appendix A.5). This approach, if successful, would
have promulgated the notion that scientific research can
resolve the knotty social issues of access to medical
care as well as extending human life.

Another approach was to attribute the problem of
access to care mainly to the lack of trained personnel.
Although in the beginning only physicians operated
dialysis machines, later, paraprofessionals were deemed
capable of performing dialysis. The problem was defined
as inadequate training for inexpensive paraprofessionals
rather than too few renal physicians or too little
equipment: ordinary human beings had not yet caught up
with the potential of the machine (Nememeek, 1962:92:
Time, 1964:42). The answer was further training to make
human beings more competent to cope with the machines
(Neweweek, 1962:92):

"Although a well-trained nurse can supervise

kidney therapy for three patients

simultaneously, more personnel are needed

before all afflicted Washingtonians can be

65

being trained 'as rapidly as possible,‘ the

twenty artificial kidneys now available will

be sufficient."

Removing control of dialysis technology from
physicians and placing it in the hands of scrupulously
trained nurse-technicians was one cost-saving move.
Other experts advocated training patients or their
helpers to conduct dialysis. The self-dialysis movement
received some of its most significant support from
dialysis pioneers, Kolff, Scribner and Merrill. By
1966, Scribner had found that most patients could be
trained in three weeks for home hemodialysis. He noted,
(1972:69) "hospital dialysis must be regarded as an
extravagance of both money and medical manpower" Dr.
Kolff, too, argued that "treatment should be done in the
home, or in community centers--not in hospitals.

Doctors should be left out of the picture almost
entirely--they're too expensive" (Time, 1968:75). His
argument for home hemodialysis was entirely pragmatic:
"It boils down to a choice between bankruptcy, death,
and do-it-yourself," (gmsgmess Week, 1967:73).

Similarly, Dr. John Merrill, of Brigham's
cardiorenal section is quoted that there is (Time
1964:64):

"no need for a physician to be in constant

attendance, provided he is within reach by

telephone. He thinks wives can be trained

to take the nurses' place, and in two cases
involving Brigham patients, they have

66

already begun to do so."

The popular press also reacted favorably to the
concept of home dialysis in descriptions of a housewife
overseeing her husband's dialysis (Life 1964:310):

"...today the [dialysis] technique has been

simplified enough so that competent,

nonpanicky people like Carolyn McHargue

can learn to operate the machines after four

or six weeks of hospital instruction."

When ESRD care was privately financed, issues of
cost control, then, were viewed as inextricably bound up
with access issues: the only way to approach equality in
access to care was to reduce costs to the point that
people with only modest means could afford it. In
support of dialysis at home, the U. S. Public Health
Services set up twelve training centers for patients,
with the goal of training at least a thousand physically
and psychologically suitable patients a year for home
dialysis (neweweek, 1970:87). By 1972, about 40% of
dialysis patients in the U.S. were dialyzing at home,
(Seience Digest, 1972:16). Advantages reported for home
dialysis were reduced rates of hepatitis, freedom of
travel, less dependency and the normalization of life
(Clark, et al., 1978:72; Alexander, 1964:31).

The problem of financial access to renal care was
finally resolved when, after being heavily lobbied and
viewing a dramatic self-dialysis by a patient named Shep

Glazer, the legislature passed H.R.1 in 1972 to take

67

effect in July, 1973 (Emanuel, 1982:12). This

legislation provided that the government would pay 80%

of most costs for both dialysis and transplantation

treatment for most end-stage renal disease patients.
Conclusions

In sum, popular press treatment of dialysis and
transplantation during the first era of reporting echoes
the stage of medical policy in the United States,
described by Paul Starr as focusing on "growth without
redistribution (1982:338)." It describes inventors,
their technologies, and actual and potential gains from
these technologies. Growth was driven by individual
efforts in a setting of scientific optimism and general
affluence.

This stage of reporting on treatments for renal
failure also reflects both values that are openly
acknowledged and suggests values that are generally
unacknowledged in American society. According to
Parsons, several values are characteristic in the United
States. First, "activism" is a value meaning that
mastery over the environment is lauded in our society;
second, "worldliness" implies the value of practical,
secular pursuits; third, "instrumentalism" implies a
value on and belief in the possibility of constant
progress, rather than contentment with the status quo

(1972:119). The popular press focus on pragmatic

68

inventor-heroes in dialysis and transplantation, on
their use of everyday materials, and on the practical,
life-saving results of their research illustrates both
the values of activism and worldliness. The increments
of success associated with improvements in the therapies
suggested an infinite fruitfulness of scientific
research in medicine, or its instrumentalism. Moreover,
the use of statistics to give hard evidence of the
benefits of practical research is based in a
positivistic notion that improvements in social life can
be scientifically measured.

When distribution of renal care came to be regarded
as a problem, this issue, too, mirrored the phase in the
nation's approach to medical policy described by Starr
as concern with "redistribution...without any
fundamental reorganization" (1982:338). Suggested
improvements in distribution of renal care were also to
be achieved without reorganization of the basic private
system of health care. Rather, scientists and others
would use their genius to cut costs of technology, thus
making the technology available to those whose lives
could be prolonged by it.

Robin Williams (1970) has cited such core values of
Americans as equality, moral orientation, and
humanitarianism. Press concern with equalizing access

to renal care and with human interest stories that

69

illustrated the worth of the technologies reflects
equality and humanitarianism. However, the moral
orientation permeating popular press rhetoric passes
beyond the secular and becomes quasi-religious, with its
references to brotherhood, sacrifice, and miracles.

In addition to these commonly discussed values,
popular reportage on renal therapy reflects implicit
values and assumptions about the nature of humanity and
its relationship to society and technology. Dialysis
and renal transplantation are, by nature, heroic medical
interventions, well suited to the tenets of allopathic
medicine, which emphasizes extreme measures in medical
intervention and views the body as a machine abstracted
from the psychological and social environment (Berliner,
1975: 576, 581). Navarro has argued that such a
mechanistic and positivistic approach is generated by
bourgeois ideology: the reductionistic focus on
technology is an effective means for medical researchers
to avoid threatening established powers that would arise
from an examination of epidemiological and structural
factors in health care (1980).

Such an approach both reflects and perpetuates
alienation. In addition to using machine metaphors for
human beings, the press uses humanizing metaphors for
machines. Marx has described such inversions as

fetishism, identifying in them a sort of idolatry in

70

which humanity admires in external objects the
properties that have been alienated from human beings:
"the productions of the human brain appear as
independent beings endowed with life and entering into
relation both with one another and the human race"
(Marx, 1967:77).

In addition to reflecting many core American
values, press coverage of a series of dramatic medical
interventions into renal care may have predisposed large
segments of the medical community as well as the lay
public to have favorable opinions and high expectations
of hemodialysis and transplantation therapies. In fact,
the rosy view of renal technology presented in the
popular press is likely have engendered a false optimism
about its potential among physicians, resulting in
inevitable disillusionment with the daily realities of
treatment of chronic renal disease. Although physicians
in the United States have traditionally resisted
government intervention into patient care, press
coverage is likely to have weakened such resistance
among renal physicians.

Emotion-laden vignettes employed in the popular
press were a deft touch. Having been socialized to a
"trained incapacity" for the appreciation of high
culture, the vast majority of Americans are easy targets

for maudlin and sentimental appeals in the media of the

71

popular culture. Press deployment of such appeals may
partly explain why renal physicians, the legislature,
and the general public eventually accepted a federal
program for the treatment of renal failure. The public,
its sentiments stirred, favored some kind of action.
Since the demand for action was based on sentiment
rather than on critical thinking and analysis, the
pseudo-socialistic program that evolved was
superficially satisfactory and minimally offensive to

all parties concerned with renal care (Olmsted, 1990).

72

Chapter 4

The Renal Disease Program in the United States

To understand the issues in renal care that have
been debated in the United States and the attitudes of
renal physicians toward them, it is necessary to
understand some technical details and vested interests
underlying these policy debates.

Before dialysis and transplantation were viable
treatment techniques for chronic kidney failure, that
condition resulted in a slow and painful death. After
World War II, technological developments in dialysis and
transplantation eventually permitted the use of both
therapies to prolong the lives of many chronic renal
disease sufferers.

Because people can survive with only one kidney,
transplantation from a living donor is a feasible
treatment for kidney failure. While Scandinavian
nations and some states in the United States perform
many renal transplants from living related donors
(Riska, 1985), most renal transplant physicians in the
United States are reluctant to perform them, citing
ethical problems such as family coercion of the donor
and the statistically small possibility that the donor
could develop renal disease and then also require
dialysis or a kidney transplant. Although good tissue

matches contribute to the success of the transplant,

73

acceptable matches may be available from either living
or cadaveric donors (Plough and Berry, 1981).

Scribner's development of a Teflon cannula, a shunt
that connects and reinforces an artery and a vein,
permitting the repeated venapuncture necessary to long-
term hemodialysis, occurred in the 1960's. In
hemodialysis, the blood is filtered by an external,
artificial kidney that removes many of the wastes no
longer removed by the patient's kidneys (Plough and
Berry, 1981). In the 1970's, improvements in sterile
techniques permitted greater use of peritoneal dialysis
as a treatment modality. The most common form of
peritoneal dialysis is CAPD (continuous ambulatory
peritoneal dialysis). In CAPD, a dialysate is placed in
the peritoneum by means of a permanently implanted
abdominal catheter. Wastes diffuse into this solution,
which is exchanged several times a day (Kutner, 1982).
Treatment Modality Mix

The technology utilized in ESRD treatment has
implications for the setting in which the treatment
occurs, and, indirectly, for the costs of the treatment.
Transplant patients, once stabilized, can be monitored
by a primary-care physician, but renal specialists
conduct frequent check-ups and deal with rejection
episodes. Hemodialysis can be conducted either by the

patient or by an assistant in the patient's home, in a

74

free-standing facility, or in a medical center. CAPD is
usually conducted, after training, in the home by the
patient or by an assistant.

The mix of treatment modalities used in treatment
of renal failure has varied both chronologically and
geographically. Over time, the trend was away from
transplantation and home hemodialysis and toward center
hemodialysis. Before federal funding of ESRD treatment
in 1972, 40% of dialysis patients underwent home
dialysis. By 1973, this figure had dropped to 33%: by
'1975, to 25%. In 1976, only 10% of new patients were
being trained for home hemodialysis (Rettig, 1979).
Although the federal government's program did not ration
renal care, permitting treatment of sicker patients who
might require center dialysis (Rettig, 1979), Blagg and
Scribner, dialysis pioneers in the state of Washington,
asserted their belief "that at least 50% of new dialysis
patients can be treated by home dialysis" (1980:501).

Variations in treatment modality utilization
occurred regionally as well as by era. In 1979, for
example, thirteen states reported that transplants
accounted for less than 5% of their treatments, while
transplants accounted for 31% of treatments in Minnesota
and 23% of treatments in Wisconsin (Relman and Rennie,
1980). Similarly, regions have varied in the rates of

home hemodialysis they have employed. In 1979, the

75

states of Washington, Utah, and Indiana led the states
in percentages of dialysis patients treated at home,
with 59%, 46%, and 43%, respectively. By contrast,
North Dakota, South Dakota, and Wyoming reported having
no patients on home dialysis (Relman and Rennie, 1980).

Finally, regions in the United States vary in the
proportions of patients being treated at for-profit
centers. In 1979, Wyoming and Delaware reported that
100% of their dialysis patients were being treated at
proprietary centers, while twelve states reported that
no dialysis patients were being treated at proprietary
centers (Relman and Rennie, 1980).
Sources of Variation in Treatment Modality Mix

Some of the variation in regional preferences for
treatment modalities and treatment settings may have its
roots in sheer medical uncertainty. Each therapy for
chronic renal failure has associated disadvantages. For
example, patients with transplants may be concerned
about such matters as life-threatening graft rejection,
reduced immunity, and cosmetic problems associated with
immunosuppressive therapy (Calland, 1972). However,
transplant recipients have more flexible schedules and
diets than do hemodialysis patients, and life table
techniques show superior life expectancies for patients
who have received transplants in comparison to patients

who have received dialysis only (Cirelli, 1984). In

76

addition, some experts argue that improvements in
immunosuppression eliminated many contraindications for
transplantation (Najarian, et al., 1977; Cirelli, 1984).
Although hemodialysis prolongs life, it also has a
number of negative consequences. Hemodialysis patients
can experience such side effects and symptoms as
cerebral edema, fatigue, and breathlessness and such
complications as fractures, infections, and bleeding
(Calland, 1972). Socially, the hemodialysis regimen
limits freedom, may lead to job loss, and requires a
restricted diet and limited fluid intake (Plough, 1981).
Both improvements in CAPD technology and meticulous
training of patients in its use have reduced incidence
of peritonitis (an infection), formerly a major drawback
in the use of peritoneal dialysis (Moncrief and
Popovich, 1979). However, most studies do not reveal
the clearcut superiority of either CAPD or hemodialysis
for patients for whom transplantation is an unsuitable
or unavailable treatment. Rather, both medically and
socially, there appear to be trade-offs associated with
the substitution of CAPD for hemodialysis. For example,
CAPD has been associated with greater normalization of
activity for children, better growth in children,
minimization of cardiovascular burden in diabetics,
facilitation of glucose regulation in diabetics, and

greater normalization of diet: yet, other research

77

indicates that CAPD interferes more with the routine of
active adults than does hemodialysis and is associated
with lower quality of life. Finally, improved sterile
techniques reduced, but did not eliminate, problems with
peritonitis that many patients using CAPD experience
(Lindsay, et al., 1981; Evans, et al., 1985).
Setting of Renal Therapy

Neither health care professionals nor social
scientists have reached consensus about the optimum
setting for hemodialysis. Some writers argue that
hemodialysis in the home by properly trained patients
relieves those patients of many of their fears by giving
them control of the process (Kutner, 1982). In
addition, flexibility in scheduling of home dialysis
makes a fuller social and work life possible (Baker and
Kaufer, 1981) and may facilitate better all-around
psychological and social adjustment (Spiedel, 1981).
However, some experts argue that patients enjoy the
social support of other patients in a hemodialysis
center and that dialysis in the home creates demands and
dependencies that are destructive of family
relationships (Plough and Berry, 1981).
Relationship of Setting and Treatment Modality to Cost

-In 1980, costs for the various treatment modalities
were reckoned as follows: living related donor

transplants, $7,709 per year of life gained: home

78

hemodialysis, $13,274; cadaveric transplant, $14,918;
and center dialysis, $24,800 (Roberts, et al., 1980).

In addition, patients' life expectancies appeared
to be best on the technologies which were utilized
least in most regions of the United States. According
to one study, for example, patients' expected survival
is 14.07 additional years after a living-related-donor
transplant; 9.5 years on home hemodialysis: 8.43 years
on center dialysis and 8.22 years with cadaveric
transplant (Roberts, et al., 1980). Many critics have
raised the question as to why the most expensive therapy
for treatment of chronic renal failure, and that in the
most costly setting, was often the most utilized.
Recently, there has been a trend away from use of in-
center hemodialysis, with increasing preference for
home peritoneal dialysis. Why have such shifts in
treatment modality emphasis occurred?

Explanations of Renal Physicians' Therapy Choices

Among health-care professionals, a popular
explanation of the shifting emphases in renal treatment
modality is that these changes reflect technological
improvements in a given modality. However, these shifts
in treatment modality mix often occur in the absence of
statistical evidence about the superiority of a
technique. Since explanations grounded in technological

superiority seem inadequate, alternative explanations,

79

both popular and academic, and grounded in psychological
and sociological insights will be explored.
Diffusion of Innovation

CAPD has quickly become a popular mode of treatment
among professionals dealing with patients with end-stage
renal disease (Deber, et al., 1985). The reasons for the
relatively widespread and rapid adoption of this medical
technology are not clear, since its adoption occurred
before any large-scale evaluations of either its
efficacy or possible long-term iatrogenic effects had
been accomplished. Deber's analysis of renal
professionals' increasing preference for CAPD and
decreasing preference for hemodialysis attributes the
recent popularity of CAPD to a "honeymoon stage" of the
diffusion of innovation (1985:108).
Human Nature

Popular theories about the causes of overuse of
the most expensive treatment modalities fell into two
basic categories: 1) human greed, 2) inept bureaucrats
and intractable bureaucracy.

In an example of the "corrupt profiteer" theory of
cost overrun, Jack Anderson wrote (1981:11):

"Like a flock of vultures, predatory medical

operators are scavenging millions of dollars

from a government-financed program essential

to keep alive thousands of victims of kidney

disease."

Such "scavenging" included centers billing

80

for nonexistent dialysis services and tests, physician
padding of bills with personal expenses, and double
billing for services. Shortly after Anderson's article
appeared, Beege;;e_2igee§ cited the names of both
practitioners and centers guilty of abusing the ESRD
program, and once again proposed home dialysis as the
solution to the problem of cost (Robinson, 1982:151).
Bureaucracy

A second popular approach stressed bureaucratic
causes of problems in the ESRD program, citing in
particular the role of the Department of Health and
Human Welfare (Marshall, 1977:18-19). Among the
failures of the program in Marshall's view: 1) HEW did
not act on its decision to put a moratorium on the
number of approved dialysis centers; 2) HEW required
home dialysis patients to rent dialysis equipment
although it was cheaper to buy it; 3) HEW refused to set
physicians' fees; 4) HEW failed to foresee and deal with
problems of profiteering and monopoly by some private
centers and 5) HEW failed to draw socially meaningful
boundaries for dialysis regions.

Ironically, insurance company bureaucrats, who
would seem to have a vested interest in cost-cutting,
were among those whose original stance helped to
impede the adoption of inexpensive home hemodialysis.

In one state, although Blue Cross would cover hospital

81

dialysis at $25,000 a year in 1972, one of its officials
argued that it would not be "in the public interest" for
Blue Cross to subsidize home hemodialysis at $5,000 a
year (geienee_gigeet, 1972:16).
Incentive Systems

Initially, renal physicians' reimbursements for
end-stage renal disease care were supposed to reflect
differences in physicians' costs and were therefore
‘higher for in-center hemodialysis than for home
hemodialysis. In addition to these incentives to center
dialysis for physicians, there were disincentives to
home dialysis for patients. Many analysts have blamed an
inappropriate incentive system for the failure of renal
physicians to adopt money-saving home hemodialysis at
the recommended rate of 50% of ESRD patients (Rennie,
1978; Baker, 1981).
The Profit Motive

Some analysts, including some renal physicians,
have charged that prior to composite capitation payment,
some nephrologists maintained too many patients on in-
center self-dialysis because of the high levels of
profit involved in this mode of treatment (Riska, 1985).
Before the institution of composite capitation payment,
profits to the physician or the center administering
end-stage-renal-disease care were highest on patients

who were otherwise medically well and able to dialyze

82

themselves at freestanding centers (Riska, 1985:112).
Physicians in proprietary dialysis centers seem to have
been extraordinarily effective in citing evidence
supporting the superiority of in-center hemodialysis,
thus blocking government interventions that might have
shifted hemodialysis from centralized facilities to the
home (Kolata, 1980a).

The research of Gardner (1981) tends to support
Riska's and Kolata's analysis. Gardner observes low
rates of transplant and home hemodialysis in networks
with a high percentage of for-profit facilities and
concludes that "...it is reasonable to believe that
'for-profit' facilities can control patterns of care in
some networks and that 'not-for-profit' facilities can
do the same in others" (1981:461-462).

Before the implementation of composite capitation
payments for renal care, the political success of
proprietary renal physicians was costly to taxpayers.
For example, Indiana has utilized high rates of home
hemodialysis (52% of dialysis patients in 1980) and high
rates of living-related-donor transplants (43% of all
transplants in 1980). It was estimated in 1980 that
adoption of such a mix of treatment modalities saved the
federal government $2.9 million annually in Indiana

alone (Roberts et al., 1980)..

83

Professional Power

Another explanation of the unexpectedly high costs
of the renal disease program attributes the high costs
to the power of renal physicians to determine renal
policy. Before the enactment of the composite
capitation payment mechanism, in the state that is the
subject of the current study, nearly 90% of dialysis was
performed in centers rather than in homes (Riska, 1985).
After the implementation of the ESRD program in 1973,
both home hemodialysis and transplantation were being
less utilized as treatment modalities in the state.

This shift to more profitable treatment modalities
occurred even though proprietary renal care centers have
never dominated renal care in the state.

Such a change in treatment modality emphasis was
not inevitable, nor did it occur uniformly in all
regions of the United States. When the legislation
supporting Federal funding of end-stage renal care was
enacted, often the renal physicians already in practice
in a region had given it a distinctive mix of treatment
modalities. The Washington state program, for example,
had high rates of self-hemodialysis at home and a strong
commitment to seeking the optimal treatment modality for
each patient. This commitment demanded a great deal of
experimentation and readjustment of treatment regimen.

Minnesota, by contrast, encouraged related-donor

84

transplant. Both of these states tended to continue to
utilize their original treatment mix, even after funding
for more expensive therapies became available through
the Federal end-stage renal disease program.

In examining reasons why there was a shift away
from home hemodialysis and toward center dialysis in
the state during the 1970's, Riska (1985) reasons as
follows: Almost inevitably, she argues, categorical
health care programs in the United States are assigned
to a single-purpose agency for administration. In the
case of the end-stage renal disease program, this
single-purpose agency was the ESRD Network Coordinating
Council, which operated on a regional level. Since
there was no provision for public representation on the
Council and only small provision for "consumer"
representation, the Network Councils were dominated by
physicians. Apparently, according to the experience in
this state, even renal physicians practicing in settings
that are non-proprietary may have interests in
maintaining patients on the most expensive treatment
modalities and may realize these interests by
participation in the Network Council. Patterns of care
in a specific ESRD region in the United States,
according to this analysis, reflect the triumph of the
judgments and interests of a specific subgroup of renal

physicians rather than reflecting professional consensus

85

about the best means for delivering high-quality, cost-
effective patient care.

Lack of a Statistical Base for Policy Decisions

Empirical support to weigh the relative merits of
each of these explanations for the adoption of treatment
modalities is made difficult by a dearth of reliable
comparative data (Rennie, 1981). Life-table techniques
have been applied to a few of the existing data bases to
compare patients' probability of survival under
different modes of treatment. (e.g., Vollmer et al.,
1983: Weller et al., 1982: Krakauer et al., 1983).
However, the usefulness of most life-table studies as a
basis for treatment decisions is compromised by their
frequent failure to standardize for factors known to
affect the life expectancy of the end-stage renal
disease patient; e.g., age at onset of ESRD, presence of
other illnesses, underlying cause of chronic renal
failure, and time in treatment. Some studies also fail
to distinguish between the survival of recipients of
transplants from living related donors and the survival
of recipients of kidneys from cadaveric donors. The
government's failure to gather meaningful and complete
statistics about the patients treated in the renal
disease program was in itself a policy decision that has
hampered its own efforts at cost control.

If factual data about life expectancy associated

86

with different ESRD treatment modalities is in short
supply in the United States, studies evaluating the ESRD
patient's quality of life under these modalities are
even less accessible and less reliable. The numerous
medical iatrogeneses associated with both dialysis and
transplantation are rarely weighed in the assessment of
patients' objective quality of life. Rather, employment
status has been the single most utilized index of the
ESRD patients' objective quality of life (Gutman et al.,
1981). Measuring subjective quality of life has been an
intractable problem in that patients, by lowering their
expectations, can increase their subjective quality of
life (Najman and Levine, 1981).
Rationing of Care Issues

A few other critics, comparing the ESRD program in
the United States with programs in European nations,
attribute part of the cost problem in the United States
to the reluctance of policy-makers to confront the issue
of rationing care. Public Law 92-603, passed in 1972,
enabled Federal funding of transplantation and dialysis,
and transformed selection processes for end-stage-renal-
disease care. In the absence of Federal guidelines
limiting care, there has been no basis for denying
patients ESRD care, regardless of their statistical
likelihood of benefiting from such care (Riska, 1985).

On a national level, this policy seems to have

87

generated greater equality in admission of end-stage-
renal-disease patients into treatment. Before the
federal program was enacted, biases, apparent only in
retrospect, were common: Blacks, now 34% of the ESRD
population, had received only 7% of the care; the
divorced, now 24.2% of the ESRD population received only
5% of the care; and those over 55, 45.7% of today's ESRD
population, received only 7% of the care before the days
of universal coverage (§Q_£lee, 1981). In addition,
women and people with lower levels of education began to
receive a greater share of treatment, more proportional
to their representation in the general population than
they had previously received (Kutner, 1982). One bias
has persisted: Blacks, at 35% of the ESRD population,
still do not receive their share of transplants (Kutner,
1987). In general, then, before the enactment of the
federal end-stage renal disease program, restriction of
benefits occurred on the basis of social criteria like
race, sex, and social class rather than on the basis of
purely medical criteria. In eliminating traditional,
but implicit, notions of social worth as the basis of
distribution of renal care, the renal disease program
also missed the opportunity to develop an explicit basis

for restricting benefits.

88

Policy and Cost-Control Initiatives

End-stage renal disease treatment remains the only
catastrophic disease for which most care is publicly
financed, and the enabling legislation was enacted
based on inaccurate projections of its eventual costs
(Rettig, 1979). Concrete actions on behalf of cost
control in health care are uncharacteristic of the
Federal government's health care programs: Initially, to
gain physician and hospital cooperation with Medicare,
government officials engaged in a "politics of
accommodation" which entailed government assurance to
private interests in medicine that government would not
attempt to control them (Starr, 1982:379). However,
because of rapidly escalating costs of health care, both
government and business began to seek reforms to reduce
these costs (Starr, 1982).

In 1978, in an effort to reduce the costs of the
renal disease program, legislation to remove economic
disincentives to home hemodialysis was enacted, with the
passage of PL 95-292 (Plough, 1981). Extensive lobbying
by National Medical Care, Inc., a private health care
group delivering center hemodialysis, succeeded in
removing quotas for home hemodialysis from this
legislation; in addition, implementation of the new
legislation was dilatory (Greenberg, 1978; Blagg and

Scribner, 1980.)

89

However, the eagerness of the Reagan administration
to shift government spending from the social welfare
sector to the military sector soon precipitated
unprecedented budgetary restraints on the Medicare
program. In 1983, the government again sought to
redress the costliness of the ESRD program. The effort
at cost control was attempted through the
implementation, in 1983, of the diagnosis-related group
(or DRG) mechanism and "composite" capitation. With the
DRG, Medicare "fixes [hospitalization] prices in advance
on a cost per case basis for inpatient services"
(Iglehart, 1983:1428). DRGs are being applied to renal
patients regardless of complications that might arise
from their renal disease. It is believed that hospitals
may encourage physicians to save money through such
means as shortening hospital stays, reducing the number
of patients treated as inpatients, and limiting
laboratory tests. It seems likely that DRG's will shift
financial and social burdens to individuals, including
ESRD patients, rather than decreasing costs of health
care (Iglehart, 1983). For example one study of
hospitals' reactions to DRG's (Gay et al., 1989)
suggests that DRGs have increased financial barriers to
care, that they have been made at the expense of
Medicare clients, that they have forced hospitals in

rural areas to close, that they discharge people who are

90

still sick, and they may inconvenience the patient by
requiring separate hospitalizations for different
conditions, rather than permitting both to be treated at
once.

Capitation had always been applied to dialysis, in
the form of a "screen," or maximum charge per treatment,
that the facility was not supposed to exceed.

Facilities treating a large number of patients with
complex problems were, however, able to apply for
exceptions to the screen. For supervising home
dialysis, the physician received a back—up payment only.
The changes introduced in 1983 established composite
capitation rates that averaged $127 per treatment, no
matter whether the treatment was conducted in a center
or in the patient's home.

Among some experts it was expected that the
implementation of composite capitation payments would
bring about rapid changes in the social and technical
organization of ESRD care delivery (Ruhe, 1984): If
facilities can encourage patients to adopt cheaper
treatment modalities, the facilities may pocket the
difference as profits. According to Lippe, dialysis
chains "all see home dialysis as a lucrative market
program" (1983:152).

The potential success of composite capitation

payment legislation may also have been improved by

91

invention in the form of improved CAPD technology, since
practitioners seem to view peritoneal dialysis as
manageable by many patients who are unable to conduct
home hemodialysis. Thus, the combination of legislation
and technological innovation may succeed in making the
home the major site of ESRD care (Deber, 1985).

However, capitation-based incentives may have occasioned
changes not only in the mix of treatment modalities
utilized in end-stage-renal-disease care, but also in
the quality of care received by patients.

In addition to facing financial pressures to adopt
less expensive treatment modalities, renal physicians'
autonomy is also threatened by the increasing proportion
of ESRD care that is being delivered by privately-owned
dialysis chains (Richman, 1985). Thus in ESRD care,
both government and corporate actions may be restraining
physicians' autonomy and reducing areas over which
physicians may dominate.

Trends

Recent changes in renal disease care, including the
corporatization of medical care, availability of
continuous ambulatory peritoneal dialysis technology,
the enactment of composite capitation payments and
implementation of diagnosis-related-group concepts have
changed the practice environment for renal physicians.

This study will evaluate the attitudes of physicians

92

toward the initial renal disease program, toward recent
policy changes, and toward other threats to their
autonomy. The implementation of laws may be carried out
in such a manner as to vitiate their intent. As Simmons
(1977:420) has noted, "all the dramatic changes
formulated on paper may, in practice, fail to produce
significant innovation, due either to the opposition of
established medical groups or to the program's own
internal flaws." Since renal physicians are involved in
both the formulation and implementation of renal care
policy, their reactions to incentives designed to
control the costs of renal care may have important cost

and quality-of-care implications.

93

Chapter 5
Research Methodology

The end-stage renal disease program in the United
States is the nation's only catastrophic disease program
whose costs are funded primarily by the federal
government. Because the federal government has
traditionally asserted few controls over the health
programs it funds (Starr, 1982), policy in government
health programs is often created by those who carry out
the programs rather than by legislators (Simmons, 1977).
In the case of the end-stage renal disease program,
those with power to carry out legislative mandates
included physicians and officials of federal and state
agencies who were assigned to oversee the end-stage
renal disease program.

Most initiatives for national health care in the
United States have proposed implementation of national
health care through the private health care delivery
system and through private insurance carriers (Margolis,
1978). Since the renal disease program was implemented
primarily through private physicians and payments were
channeled through private insurance intermediaries,
the characteristics (both strengths and weaknesses) of
the end-stage renal disease program are likely to be
features of any similar national health care program.

If, as Freidson has argued, professional dominance

94

.is related to the inadequacy of health services
(l970a:xi), studying physicians' attitudes about autonomy
and power within the renal disease program can provide
insights into the dynamics of the development of
professionally created inadequacies in national health
services. Because renal physicians enjoyed relative
autonomy under the mandates of the end-stage renal
disease program, especially during its initial stages,
it is important to study their role in shaping the
program and to examine the social costs and benefits of
a publicly funded program that ceded levels of power to
private physicians that are unparalleled in other
nations' public health care systems. This study will
draw on survey data and interview data in analyzing the
role of renal physicians' attitudes about their autonomy
in the development of the end-stage renal disease
program within the state.
The Surveys

The questionnaires explore the attitudes of renal
physicians in the state about the end-stage renal
disease program, as reported in two mail surveys,
conducted in both 1980 and 1987. According to previous
studies, both the sociodemographic characteristics of
physicians and the characteristics of their medical
practice settings may be related to their attitudes

about issues in medical care. The 1980 and 1987 surveys

95

sought to ascertain whether the attitudes of renal‘
physicians in the state toward the end-stage renal
disease program would exhibit the same kinds of_
relationships to sociodemographic and social structural
variables that have been reported in earlier studies.

The 1980 and 1987 surveys of renal physicians in
the state emphasized three general concerns that had
emerged during the time renal physicians had been
dealing with the federal end-stage renal disease
program. First, since physicians have often resisted
proposals for federally-sponsored health care programs
in the United States as instances of socialized
medicine and as attacks on their professional autonomy,
the first concern involved renal physicians' perceptions
of their autonomy within the federal government's end-
stage renal disease program. A second issue involved
renal physicians' perceptions of threats to their
autonomy that arose from non-governmental sources (such
as the entrance of private profit-making chains into
renal care). A final concern involved renal physicians'
assessment of the quality of the program they had been
instrumental in shaping.

In 1980 Elianne Riska surveyed renal physicians in
the state to assess their opinions on a number of
questions relating to these issues. At the time of the

1980 survey, the federal government, through insurance

96

intermediaries, had been reimbursing 80% of costs of the
treatment of end-stage renal disease for about seven
years. Respondents to the 1980 survey were therefore
answering questions about a program with which most were
very familiar. In 1987, I partially replicated Elianne
Riska's survey, updating it to reflect recent
developments and controversies surrounding the end-stage
renal disease program.

Between 1980 and 1987, efforts by the federal
government and by insurance intermediaries to control
health-care costs resulted in the application of‘
prospective payment mechanisms--composite capitation
rates and diagnosis-related-group concepts--to the end-
stage renal disease program. Composite capitation
payment meant that renal physicians were reimbursed at a
per-patient rate and could maximize their earnings by
prescribing therapies that were least costly to the
physician to administer. The diagnosis-related-group
concept, in application to renal physicians, meant that
treatment of a hospitalized patient's acute or chronic
renal failure was unlikely to be covered by the group
rates.

By 1987, the federal administration had also
attempted to eliminate support for the End-Stage Renal
Disease Network Coordinating Council, the organization

through which renal physicians advised the government on

97

policy issues and made local renal program policy
decisions. The Network Council had been relatively
active and well-organized in the state that is the
subject of this survey. Although Congress restored
funding for the Network Council, the attempted
dissolution of the Council was further evidence of the
degree of ferment in the renal care program. One aim of
the follow-up study is to ascertain physicians'
attitudes toward the government's stepped-up efforts to
gain increased control of the end-stage renal disease
program and to remove the formal structure through which
renal physicians were allowed a voice in the program.
Questionnaire Construction

Elianne Riska devised the 1980 survey of renal
physicians, focusing on their reactions to issues of
power and autonomy within the federal renal disease
program. The 1980 survey of renal physicians in the
state was revised in 1987, with changes in the survey
.to reflect changes in the program that occurred after
the first survey was completed. The revised survey
was evaluated by three nephrologists and one state
official who made suggestions about further revisions.
Changes from the 1980 surveys were generally made, in
accordance with the suggestions of the reviewers, to
clarify the intent of the question, to reflect recent

developments in renal policy and to keep the survey

98

reasonably short, given physicians' characteristic low
response rate to mailed questionnaires.

Inevitably, keeping the survey short while
incorporating questions on physicians' reactions to
recent federal policy changes, entailed eliminating some
questions that had been on the 1980 survey. For these
questions, the possibility of gaining longitudinal
information was lost. Issues about which the renal
physicians had very high levels of agreement in 1980
were those that were most likely to be eliminated from
the 1987 survey. Independent variable categories that,
in 1980, had too few cases to permit meaningful analysis
(such as whether the renal physician had osteopathic or
allopathic medical school training) were also dropped
from the 1987 survey.

The 1980 survey began with sociodemographic
information and clustered questions according to topic.
The questions designed to assess physicians' attitudes
about the end-stage renal disease program were not
grouped according to topic in the 1987 questionnaire;
rather, there was an attempt to place the most
interesting and least politically sensitive questions
first, the more politically sensitive questions later,
and sociodemographic questions last. On the 1987
survey, physicians were provided an opportunity to check

off whether they wanted to receive a summary of the

99

.results of the 1980 and 1987 studies. The questions
from both surveys are reproduced in Appendix B.
Sample Selection

Although the Federal government's end-stage renal
disease program is often treated as a demonstration
project for national health care, it would be a mistake
to regard the program as a uniform national program.
The end-stage renal disease program is funded by the
Federal government, but it was grafted onto a number of
pre-existing regional situations, a few of which were
organized enough to be considered state-level programs.
Contrasts between regions are abundant, and there is
little reason to believe that any two regional programs
have enough similarity of history and policy to enable
meaningful comparisons between regions to be drawn.
Rather than speaking of a national end-stage renal
care program, it is more accurate to speak of a number
of regional programs. Because review and analysis of
the political and historical factors that differentiate
the end-stage renal disease regions in the United States
is beyond the scope of this study, this study was
limited to one region of the United States, a region
comprised of most of one midwestern state. For this
reason, all the physician-respondents come from only one

state.

In 1980, Elianne Riska constructed and mailed the

100

first survey of renal physicians in the state to the 105
renal physicians practicing in the state. The mailing
list was obtained from the Kidney Foundation's 1980
directory of renal physicians. In 1980, 65% of the
state's renal physicians responded to the survey (n=68).

The initial mailing list for the 1987 survey was
obtained from the National Kidney Foundation's 1986
directory of end-stage renal disease treatment
facilities in the state. Because of the relatively high
rates of turnover for renal physicians involved in end-
stage renal disease care in the state, revealed by a
comparison of Kidney Foundation directories from 1980
and 1986, every facility in the state was telephoned to
obtain an updated list of names and addresses of the
renal physicians practicing at that facility. Telephone
directories from major cities in the state provided the
names of other renal physicians, whose offices were also
called to verify the locations of their practices and
their involvement in end-stage renal disease care. One
of the reviewers of the survey suggested these telephone
verifications of renal physicians' practices.

In 1987, revised questionnaires with a letter (see
Appendix D) explaining the purpose of the research and a
self-addressed, stamped envelope were mailed to all of
the 128 renal physicians listed as practicing in the

state. Of these, three wrote that they either no longer

101

practiced renal care or that they no longer practiced in
the state, leaving a total of 125 renal physicians in
the sample. After several weeks, a postcard reminder
requesting that nonrespondents fill out the
questionnaire was mailed. After several more weeks, a
second questionnaire with a letter reviewing the purpose
of the study and a second return envelope were mailed to
the remaining nonrespondents. The 1987 response rate
was 68 per cent (n=85).
Sample Characteristics

The characteristics of the physicians responding to
the survey were relatively stable between 1980 and
1987 (see Table 5.1). The biggest change in respondent
characteristics is that they were less likely to belong
to five or more professional medical associations in
1987 than in 1980. Another relatively large change is
the 1987 increase in the percentage of respondents who
had been in renal care more than eight years at the time
of the survey. These two changes may be related: As
physicians gained practical experience, they may have
felt less need for the sort of indirect socialization
available through membership in renal physicians'
organizations. The increase in the number of more-
experienced renal physicians among the 1987 respondents
could mean that clinical and practical experience played

a greater role in shaping physicians' responses in 1987

102

than in 1980. Because only a few women and minority
renal physicians practiced in the state, sex and race
were not used as independent variables.

It is intriguing to speculate how responses of
physicians educated in other nations might compare with
those educated in the United States, which emphasizes
medicine as a market commodity. Although specific
breakdowns into national groups are not available for
the 1980 study, in 1987, thirty-one renal physicians had
been educated in fifteen other nations. These nations
differed in socioeconomic structure and type of health
care system. Some were western industrialized nations
with socialized medicine, some less industrialized
nations also had systems of socialized medicine, and in
some, allopathic physicians faced competition from
herbalists and other traditional healers. Subdivision
of physicians educated abroad into these categories
would result in numbers to small to permit statistical
analysis; therefore, I will retain only two categories,
whether educated abroad or in the United States.

In 1980, respondents were not identified by
name or practice facility. Thus, it is impossible to
compare the answers of individual physicians in 1987
with their answers in 1980. Rather, the table that
follows compares all the respondents from the state's

renal physician population in 1980 to those of 1987.

103

Table 5.1. Characteristics of physicians responding to

survey.

Location of practice
Metropolitan
Outstate

Specialty
Nephrologist
Transplant surgeon
Other

Type of practice
Solo
Single-specialty
Multi-specialty
Medical faculty

Setting of practice
Office
Hospital
Other

Time spent in
for-profit setting
50% or more
Less than 50%

Income in salary
50% or more
Less than 50%

Medical education
Abroad
U.S.

Professional meetings
attended in a year
Four or fewer
Five or more

Membership in professional
organizations*

Four or fewer

Five or more

Years in renal care*
Seven or fewer
Eight or more

*Statistically significant at the 9:.05 level.

1980

50.8%
49.2%

69.1%
19.1%
3.3%

16.2%
30.9%
19.1%
33.8%

30.9%
48.5%
20.6%

13.2%
79.4%

68.3%
31.7%

31.8%
68.2%

64.2%
35.8%

44.8%
55.2%

45.6%
54.4%

1987

53.6%
46.4%

78.8%
12.9%
8.2%

12.2%
42.7%
14.6%
31.5%

22.4%
41.2%
36.5%

15.8%
84.2%

60.0%
40.0%

37.8%
62.2%

71.1%
28.9%

78.5%
21.5%

24.1%
75.9%

'Interviews

In addition to the survey data, interviews of renal
physicians in leadership positions in the state's renal
care program and officials of state agencies associated
with the end-stage renal disease program were
conducted in 1979-80. Elianne Riska and a member
of her staff conducted the interviews. Physicians and
agency officials who had been leaders in the state's
end-stage renal disease program were identified through
written histories of the program and through
identification by other leaders. In 1980, eighteen
renal physicians and agency officials were interviewed.
In 1987, I interviewed three renal physicians and one
agency official to find out what changes in the survey
instrument would be needed because of recent changes in
ESRD legislation and technology. All but two of the
interviews were tape recorded and transcribed. The two
remaining interviews were summarized immediately after
the interviews. Dr. Riska has provided me with access
to both her survey data and her interview data for use
in this study.
Analysis of the Data

Since the 1980 data do not identify individual
physicians, it is not possible to trace changes in the
attitudes of individual physicians between 1980 and

1987. However, both stability and change in attitudes

105

for the group of renal physicians as a whole are
reported in this study. Indeed, issues on which
physician's attitudes remained stable, despite rapid
changes in federal legislation and in renal technology,
may be indicative of values that are deeply held.

For this exploratory portion of the analysis, an overall
view of the data, results are given in percentages.

In addition to this overview of the data, the
relationships between sociodemographic and social
structural variables and physicians' attitudes to renal
policy issues are reported. Because of the small sizes
of survey respondent groups in both 1980 and 1987, the
results of these surveys will not stand up to regression
analysis: therefore crosstabulations have been
performed. Levels of significance 9:.05 or less will be
considered significant. Because Chi-square is
considered an already conservative test of significance,
levels of significance will be reported without the
Yates' correction. In all instances where the expected
number of cases in each cell is fewer than five, this
will be clearly noted: however, findings based on small
cell sizes will be reported. Because of the small size
of the sample, failure to report these findings might
discard useful information. The Chi-square levels of
significance for relationships between all independent

and dependent variables will be summarized in Appendix

106

B. Again, where the expected number of cases in each
cell is fewer than five, this will be clearly noted in
the Appendix B figures. Because of the small size of
the sample, responses were collapsed into similar
categories; for example, "Strongly agree" and "Agree"
were collapsed into an "agree" category. "Undecided"
responses were omitted from the Chi-square analysis.
The renal physicians' responses to the survey will be
compared to prior studies of physicians' reactions to
other federal innovations such as Medicare, capitation
payment, certificate-of-need requirements, and proposals
for national health insurance.

Information drawn from interviews with renal
physicians and agency officials will be used, where
relevant, to supplement the information gained from the
1980 and 1987 surveys of renal physicians. These
interviews provide both factual information and insights
about social and political dynamics in the renal care
program. Such facts and insights are useful in the
interpretation of the quantitative survey data and
illustrate the advantages of using more than one type
and source of data. These interviews were transcribed
and coded for relevance to the issues probed by the mail
questionnaire: Physician autonomy, renal program policy
development, and quality of the federal government's

renal care program. The interviews provide physicians'

107

and agency officials' accounts of their understandings
about the causes of problems that arose in the renal
disease program. The interviews also provide detailed
information about some of the conflicting interests of
various groups involved in the program and their
political activities in resolving the issues that arose
in the region. Finally, the interviews provide many
background details about the history of the treatment of
end-stage renal disease in the state that are not
available through more formal sources.

Sample Generalizability

The federal government's end-stage renal disease
program cannot be examined on a national level because
it was implemented on a regional level. The regional
end-stage renal disease programs must answer to numerous
state- and federal-level health agencies which divide
control over various aspects of the program. In the
regions that consist of more than one state, problems of
coordination and consistency are multiplied.

Some states had relatively well-organized systems
for delivering end-stage renal disease care even before
the federal end-stage renal disease program was enacted,
and others had little effective organization of end-
stage renal disease care delivery. After implementation
of the federal end-stage renal disease program, some

states came to be dominated by academic physicians,

108

others by physicians practicing in proprietary settings,
and still others by physicians from large hospitals. In
the state that is the subject of this survey, although
physicians practicing in proprietary settings were and
have remained a minority, no single group of renal
physicians emerged to dominate renal policy in the state
or to manipulate policy in such a way as to drive
physicians in certain practice settings out of end-
stage renal disease care delivery. Therefore, this
state cannot be compared to states in which a single
type of renal physician dominated regional renal policy
and articulated policy in line with its own interests.
Because of all of these sources of diversity,
rather than speaking of a national end-stage renal
disease program, it is more accurate to speak of a
loose federation of regional programs. .Because end-
stage renal disease regions contrast fundamentally with
one another, there is little reason to believe that any
two regional programs have enough similarity of history
and policy to enable meaningful comparisons between
regions to be drawn. Rather, the findings of this
study will be interpreted as elements of a single case
study of one of many regional programs that evolved in a
loosely structured federal health care program that was
implemented and delivered primarily through the private

system of health care.

109

Future Studies

It would be fruitful to examine the development of
renal policy in the various regions of the nation. Each
is a case study in a different organization of renal
care in a specific social, geographic, and historic
setting. However, given the difficulty of interpreting
the results of objective surveys and given the human
tendency to hold contradictory viewpoints, it would be
useful to survey physicians as part of an interview to
permit elaboration on their views.

Conclusions

In summary this study will probe the state's
renal physicians' opinions about the end-stage renal
disease program, and attempt to relate those attitudes
to social structural and sociodemographic variables.
Because the renal disease program was regionalized and
because each region sought to develop policy within a
loosely structured federal framework, physicians'
efforts to assert power over federal policy must be
studied at a regional level. This is a case study of

one such region.

110

Chapter 6
Issues of Physician Autonomy
Recently, in his widely acclaimed analysis of
medicine in the United States, Paul Starr (1982) has
argued that assaults on physicians' autonomy are
occurring on two fronts: through government attempts to
control health care costs and through corporations'
increasing dominance of medicine. Physicians, he
argues, are highly conscious of government constraints
on their autonomy but are less conscious of the greater
loss of autonomy (1982) likely to result from the
increasing ownership of health care facilities by large
corporations. Another analyst of modern medicine, Haug
(1976), cites a third threat to physician autonomy: the
consumer movement has produced patients who are experts
and who challenge physicians' claims of expertise as
justification of their professional autonomy.
Threats to Physician Autonomy
Because the end-stage renal disease program is a
federally funded one, with potential for private
business profit and oligopoly control, renal physicians
should be acutely aware of potential threats to their
autonomy from these two sources. The enabling
legislation for the federal end-stage renal-disease
program, PL92-603, an amendment to the 1965 Medicare act

and implemented in 1973, imposed minimal (but

111

vociferously protested) constraints on the renal
physicians involved in the program: Certificates of need
were required for new dialysis facilities; a maximum
payment (or screen) per dialysis was established, with
provisions for exceptions for facilities treating
patients with unusually complex problems; and regions
were required to establish Network Councils to advise
government administrative agencies, to plan regional
policy, and to monitor quality of care (Riska, 1985).

Renal patients, like other chronic patients, often
become experts on their own conditions (Plough, 1981).
In addition, federal guidelines mandated consumer seats
on the End-Stage Renal Disease Network Coordinating
Council. Renal physicians should therefore be aware of
"consumerist" threats to their autonomy at both
macropolitical and micropolitical levels.

Since the establishment of the renal disease
program, several trends have emerged, both more
threatening to physicians' autonomy than the original
provisions of the end-stage renal disease program.
Government efforts at cost control have taken the form
of composite capitation payments for ongoing care of
renal patients and the application of the diagnosis-
related-group concept to renal patients who are
hospitalized. In addition, national proprietary

conglomerates have been increasingly predominant in

112

renal care, both as producers of dialysis equipment, as
owners of dialysis facilities, and as employers of renal
physicians. This study sought information about
physicians' perceptions of consumer, government, and
corporate threats to their autonomy.
Corporate and Government Threats to Physician Autonomy
Physician responses on autonomy issues partially
support Starr's notion that physicians are more
concerned about government constraints on physicians
than about similar corporate constraints. A clear
majority, 65.9%, indicated that government has an
important effect in limiting physicians' autonomy, while
fewer--41.2%--agreed that corporations have a similar
effect (see Table 6.1).

Table 6.1. Outside agencies place important
limits on physician autonomy, 1987.

Government Corporations
limits limit
autonomy. autonomy.

Yes 65.9% 41.2%

No 32.9% 37.6%

No Answer/ 1.2% 21.2%

Undecided

The one fifth of respondents who did not commit
themselves on the issue of corporate constraints are
perhaps too unfamiliar with corporate practice to
evaluate the issue: Several wrote on their surveys that

they didn't know enough about proprietary practices to

113

answer the question. "Deregulation" and "private
enterprise" were the watchwords of the Reagan era:
Physicians' views of corporations as less threatening to
their autonomy than government may partly reflect
prevailing political rhetoric. In addition, political
activities of the state's non-proprietary renal
physicians in the state's Network Coordinating Council
had limited the expansion of the large corporations that
dominate renal care in many other states. This success
may explain why fewer than half of them evaluated large-
scale corporate practice as an important threat to
physicians' autonomy. Finally, technical advances in
continuous ambulatory peritoneal dialysis have increased
the possibility that renal care can be run on the model
of a cottage industry. Because it is conducted in the
homes of all but the sickest patients, this technology
makes it easier for renal physicians to practice alone
or in small corporations and may act as a further
barrier to large corporations' expansion into renal care
in the state. Despite corporations' posing little
immediate threat in the state, a substantial minority of
renal physicians did regard large corporations as
placing important constraints on physician autonomy.
ESRD Program Planning

Planning of medical programs involves potential

threats to physicians' autonomy in the "content of work"

114

(essential to claims of professionalism) if it
interferes with such matters as diagnosis, treatment
decisions, and the right to have medical work evaluated
by colleagues (Freidson, l970a). Such threats were
slight in the original-ESRD program: after 1972, within
the minimal guidelines of the initial federal program,
renal physicians were relatively free, through Network
Councils, to run their own regional programs. There was
no body of physicians at the federal level comparable to
the Network Council; nor was any single federal agency
charged with responsibility to plan the ESRD program.
There was remarkably little active planning of the ESRD
program at either federal or state levels: Agencies
tended to react to problems as they occurred rather than
to anticipate and plan for them (Riska, 1985).

It is likely that most of the state's renal
physicians in 1980 had been involved in planning the
state's end-stage renal disease program before federal
funding was available. Their satisfaction with that
early program, as well as with the activities of the
Network Council, may explain why nearly all of them
preferred that medical professionals plan the end-stage
renal disease program (see Table 6.2). Essentially,
they were expressing approval of the past and of the

status quo.

115

Table 6.2. Agreement that the medical
profession should plan the ESRD program, 1980.

Agree 91.2%
Disagree 4.4%
Undecided/No Answer 4.4%

ESRD Program Administration

Administration of governmental programs is likely
to involve decisions about the "terms of work" (e.g.,
when, where, for what price work will be conducted), not
essential to claims of professionalism (Freidson,
1970a). However, nearly all renal physicians agreed it
was important for medical professionals to administer
the ESRD program (see Table 6.3). Physicians in the
United States have traditionally enjoyed autonomy over
both content and terms of work, and their answers could
reflect reluctance to tamper with the status quo.
However, since at least six governmental agencies were
involved in administering the ESRD program (Riska,
1985), physicians' answers to this question may be as
much an objection to this cumbersome administrative
. structure as a statement of professional autonomy.
Regulation of the ESRD Program

Although most renal physicians in the state agreed
that planning and administration of the ESRD program
should be the province of the medical profession, such a

preference did not prevent their conceding the right of

116

Table 6.3. The medical profession should
administer the ESRD program, 1980.

Agree 89.7%
Disagree 7.3%
Undecided/No Answer 2.9%

Table 6.4. Physicians' agreement that the
government should regulate the ESRD program.

1980 1987
Agree 50.0% 56.5%
Disagree 47.0% 36.4%
Undecided/ 2.9% 7.1%

No Answer

117

the government to regulate the program (see Table 6.4).

The percentage of physicians opposing government
regulation of the program has declined between 1980 and
1987. This decline might partially reflect the changing
composition of the state's renal physicians, since those
most opposed to government regulation might have left
the state or left renal practice entirely. The decline
might also reflect renal physicians' recognition that
government regulation was necessary to reduce abuses of
the renal disease program by the incompetent and/or the
unscrupulous. A salaried nephrologist, dubious about
both government bureaucracy and entrepreneurial renal
care, articulated his concerns:

"I think there is such room for abuse that

although I'm very impatient with the

bureaucracy of the government and the

ponderousness of its moves, on balance again,

I think it's for the best, because out of

control, I'm scared about what the profit

units in particular might do. But that's

perhaps a little unfair, because it could

easily be argued I should also be scared about

[what] second-rate people or hospitals might

do. It's a pistol...."
Autonomy Through the ESRD Network Council

The vehicles designated to allow for renal
physician input into the ESRD program were the End-Stage
Renal Disease Network Coordinating Councils. The
Councils were intended to provide a forum where

physicians and a few representatives of other interested

groups could act-as an advisory body to state agencies,

118

maintain quality-of-care in the region, and work out
regional policy issues.

Regional ESRD Network Coordinating Councils
apparently afforded the majority of physicians a sense
of being somewhat but not very influential in
establishing renal policy (see Table 6.5).

Table 6.5. Renal physicians' evaluation of
their influence on renal policy.

1980
Very influential 27.9%
Somewhat influential 48.6%
Not influential 4.4%
Undecided/No Answer 19.1%

Although the Council had little formal legal
power, one nephrologist described the dynamics of the
ESRD Network Coordinating Council as follows:

"Over the period they tried to anticipate what
was going on at the federal level, and I think
there was a lot of spirit of cooperative
effort with the federal government, so that
there wasn't an adversarial relationship all
of the time with the people of the
bureaucracy. There was a feeling that the
people in the bureaucracy really didn't have
all of the answers and they were struggling
too, and they wanted to do the right thing,
and they weren't sure what the right thing
was..."

Within the state, greater power to Councils would
have restored to many renal physicians a measure of the
local political power they had enjoyed before the
enactment of the federal program, through participation
in the Transplant Society and the Kidney Foundation.

119

However, the majority of respondents indicated little
interest in strengthening the advisory—reactive role of
the Network Council (see Table 6.6). Such results
reflect no strong physician demand, in 1980, that renal
physicians' collective political influence be increased.
Perhaps physicians not wanting more power for the
Council shared the skepticism about policy-making
through vested interest groups found in a colleague's
critique of the Council:

"...it's just an abomination....an exercise in

futility. People working very hard to be sure
their own self-interest is assured."

Table 6.6. The degree of power Network
Coordinating Council should have.

1980
More power 20.6%
Has enough power 51.5%
Should have less power 11.7%
Undecided/No Answer 16.2%

From 1973 to 1987, Network Councils apparently
wielded influence over the renal disease program through
the "cultural authority" of physicians; and, until
recently, the federal government has been wary about
challenging that authority (Starr, 1982). However, by
1987, the federal government had attempted to dissolve
the Networks, only to have Congress reinstate funding
for the activities of the Networks for a year. Because

the continuing status of the Network Councils was

120

uncertain in 1987, questions about the Councils
were not repeated in the second survey.
Consumer Involvement in Policy-making

The ESRD program provided for three "consumer"
seats on the regional Network Council. Since 1980,
renal physicians' receptiveness to consumer input into
ESRD policy has increased (see Table 6.7).

Table 6.7. Consumers should have more voice
in renal care policy.

1980 1987
Agree 51.4% 67.0%
Disagree 39.7% 24.7%
Undecided/ 8.8% 8.2%

NO Answer

What this increased openness to consumer input
means is unclear. Under the present system of
categorical health programs controlled by numerous
agencies, renal physicians have little reason to fear
that increased consumer involvement in policy-making
threatens their autonomy. Current levels of consumer
participation have not threatened physicians: According
to Riska, "the role of the consumer representatives on
the Network Council has mainly the character of
tokenism" (1985:120). However, the greater openness of
renal physicians who were medically educated abroad to
increased consumer participation (see Table C.7) may
indicate that physicians socialized into more

121

centralized and democratic systems of health care during
medical school view increased consumer participation
more positively than do those renal physicians who have
not experienced first-hand exposure to other nations'
systems for determining health and medical policy.
Autonomy in Treatment Decisions

Choice of treatment modality is an issue that
involves physicians' autonomy on the micropolitical
level. Most respondents agree that the nephrologist
currently has most influence in selecting the treatment
modality for renal disease, but view the patient as
somewhat more influential in 1987 than in 1980 (see
Table 6.8). The patient's gain in influence by 1987 -
appears to be viewed as the nephrologist's loss, with
roughly 8% viewing patients as gaining influence and
roughly 8% viewing physicians as losing influence
between 1980 and 1987. Perceptions of increasing
patient influence may result from both medical schools'
and malpractice insurers' recent emphasis on the

patients' "informed consent" to treatment.

122

Table 6.8. Who presently has the most
influence on the treatment decision.

1980 1987
Nephrologist 77.6% 69.4%
Patient 9.0% 17.6%
Patient's family 3.0% 3.5%
Other/ 10.5% 9.4%
No answer/
Undecided

Table 6.9. What the patient's role in the
treatment decision gaggle be.

1980 1987
More influence 41.2% 37.6%
Influence as is 48.5% 58.8%
Less influence 4.4% 1.2%
Undecided/ 5.8% 2.4%

No answer

123

The majority of respondents prefer the present
level of patient influence over treatment modality
selection, although a substantial minority would be
willing to grant the patient more influence in selecting
a treatment modality (see Table 6.9).

Plough has argued that patients with chronic
diseases tend to become experts on their own
conditions, capable of meaningful contributions about
their symptoms, prognoses and treatments (1981). Renal
patients, then, should be eminently qualified to choose
their own therapies: however, a more egalitarian pattern
of decision-making would require physicians to sacrifice
autonomy in the critical area of content of work. Only
a minority of physicians seems willing that either
surgeons or nephrologists have less influence over the
treatment decision (see Table 6.10).

Table 6.10. Type of renal physician and

degree of influence each should have on

treatment decision, 1980.

Nephrologist Transplant

Surgeon
More influence 13.2% 11.8%
Influence as is 48.5% 58.8%
Less influence 20.6% 23.5%
Undecided/ 4.4% 7.3%

NO answer

One interpretation of the seemingly conflicting
findings, with many physicians willing to increase
patient influence but most wanting to keep physician

124

influence as it is, is that physicians believe they can
ultimately influence the treatment decision, while
giving patients more of an opportunity to express their
opinions. Physicians appear to view influence in
therapy selection as a "non-zero-sum game": giving
patients more influence may not necessarily diminish
their own influence.
Cost Containment Policy

By 1978, federal officials had become concerned
about the unexpectedly high costs of the ESRD program,
and began to explore various measures to limit those
costs. Inevitably, physicians perceive cost containment
measures as threats to both their incomes and their
professional autonomy. The present study includes
questions about the state's renal physicians' attitudes
on three types of cost-containment strategy: controls on
the numbers of dialysis and transplant centers eligible
for federal reimbursement: inducements to reduce costs
of therapy: and outright rationing of ESRD care.
Certificate-of-Need

The federal government's original ESRD program
required that, to receive reimbursement, dialysis
facilities must obtain certificates of need, or
statements that present treatment facilities are
inadequate to treat all patients with kidney failure in

the region. The requirement for certificate of need was

125

implemented to "avoid unnecessary duplication of
expensive services and equipment" (Pruchansky, 1983).

In addition, some proponents of certificate-of-need
argue that in areas that are "overdoctored," demand for
care has, in some instances, risen to meet supply: thus,
physician-created demand drives up national health care
costs (Rice, 1983). Finally, many observers have noted.
that conditions necessary to a "marketplace" do not
obtain in health care: thus, the free market approach is
inapplicable to health care (Mechanic, 1978; Weisbrod,
1983).

Opponents of certificate-of-need policies in health
care usually couch their opposition in free-market
terminology. Alford describes opponents as "market
reformers," (1972:129) who argue that patients' freedom
to choose from among several providers will eliminate
such problems as incompetence among providers, unfairly
high prices, and inaccessible services. In addition,
some "market reformers" argue that certificate-of—need
requirements have spawned "medical monopolies," enabled
by their monopoly status to ignore both quality of
patient care and costs associated with that care.
(Greenspan, 1981).

After 1972, with payment assured and high levels of
profit possible, end-stage-renal-disease care became

attractive to physicians and facilities that had not

126

been involved in it earlier. Thus, one important issue
in the state involved whether certificate-of-need
requirements should be suspended, allowing new dialysis
facilities to compete freely with older facilities. In
addition, some renal physicians practicing in
established facilities wanted to expand the number of
their dialysis stations. An agency official described
the motivations to expand services at the different
types of facilities:

"As they try to expand there's going to be a

constant competition for expansion. Hospitals

will want to expand so that they can maintain

the units that they have on a more efficient

basis and be able to not run in the red and

these [proprietary] units will want to spring

up because they are profitable. And there is

going to be a constant fight to expand

facilities."

At the time of the second survey of the state's
renal physicians, although some ESRD regions in the
:nation had suspended certificate-of-need requirements,
‘they remained in effect in the state. Renal physicians
.in the state were quite evenly divided on the
«certificate-of-need issue (see Table 6.11). In both
years, approximately two fifths of renal physicians

(those disagreeing with the statement) took a position

(mantrary to support of a free market in renal care.

127

Table 6.11. Physicians' opinions about whether
qualified physicians should be able to enter
renal care, regardless of need for services.

1980 1987
Agree 45.6% 42.4%
Disagree 42.6% 41.2%
Undecided/ 11.7% 16.5%

N 0 Answer

Many observers have noted that most capitalists who
employ free-market jargon do not apply it to their own
businesses, welcoming whatever advantages accrue to them
from an oligopoly or monopoly position in these markets.
Regardless of their personal political beliefs about the
free market, renal physicians practicing in established
facilities, whether proprietary or nonproprietary, had
vested interests in opposing certificate-of-need for
themselves but to welcome its application to other
dialysis facilities. Between 1973 and 1987,
certificate-of-need requirements appear to have
functioned esentially to preserve entrenched interests
(Riska, 1985). Conflicting vested interests undoubtedly
lhelp to explain high levels of support for a mechanism
‘that is contrary to the tenets of the free market. In
addition, solo practitioners, most of whom were exempt
from certificate-of-need requirements, had no vested

iJTterests in opposing them. Finally, perhaps some of

128

the relatively liberal response to this question
reflects a traditional attitude that professionals
should be above blatantly economic considerations.
Regionalization of Transplant

The traditional view on renal transplantation is
that, like all complicated surgeries, it is best
conducted in university research centers. Patient
survival is supposed to be improved when surgical teams
have a frequent experience in coordinating delicate
procedures, so that the surgery becomes almost routine
to them. In addition, frequent surgeries permit the
accumulation of either written or folkloric research
records to provide an enlightened basis for future
surgeries. Transplantation capability also lends
prestige to a medical center (Kutner, 1987). From the
cost-control viewpoint, preventing duplication of
expensive transplant facilities should bring about cost
savings. The government proposed to accomplish
regionalization of transplant facilities by closing all
transplant centers that did not perform at least fifteen
‘transplants a year (Riska, 1985). Respondents in the
state tended to support regionalization of transplant

facilities (see Table 6.12) .

129

Table 6.12. Renal transplantation should be
conducted only in a few transplant centers.

1980 1987
Agree 54.4% 68.2%
Disagree 41.2% 29.4%
Undecided/ 4.4% 2.4%

No Answer

Not all renal physicians accepted received theory
about the superior work performed at regionalized
transplantation centers. One nephrologist cited costs
and benefits that are not usually part of the
regulator's calculations:

"We got into the transplantation business
because a substantial number of our patients
did not want to drive down to [the University
Center] once a week or once every other week
or once a month for follow-up. They didn't
want to have to deal with having people
involved in transplantation turn over every
two weeks, which has been the norm at [the
University Center], with the young Turks who
come on, who are working their way up the
academic ladder....We think that [stable
staffing] probably plays a part in--that's one
of the variables that impacts on the goodness
of patient care. We really do. We haven't
proven that, but we just intuitively think
that's a reasonable hypothesis."

By 1987, several facilities had dropped out of
transplantation, but none had been forced to do so by
the government. Between 1980 and 1987, declining
opposition to regionalization of transplant centers may
reflect a sense that the threat of closure had been

removed for existing transplant facilities.

130

Therapy Choice

Generous reimbursements for in-center dialysis and
physicians' fees, combined with disincentives to the
less-expensive home hemodialysis resulted in a situation
in which, a few years after the passage of the ESRD
legislation, only 25% of patients in the nation were on
home hemodialysis (Marshall, 1977). By 1981, the
proportion of patients in the United States that was
dialyzing at home had shrunk to 13% (Robinson, 1981).

In 1980, the state being surveyed followed national
trends in moving away from employment of less-expensive
self-dialysis at home to costly in-center dialysis.

In 1978, legislation to require that 50% of ESRD
patients be on home hemodialysis was defeated after
intense lobbying by large-scale proprietary dialysis
interests (Kolata, 1980b). It is likely the proprietary
dialysis interests were supported in their opposition to
quotas for home hemodialysis by unlikely allies: renal
physicians primarily concerned with the psychological
and physical well-being of their patients rather than
with profits. One salaried nephrologist explained his
preference for in-center self-dialysis:

"There's a minimum of staff. They take care

of themselves. That's a very happy place.

They kid around with one another; they are

just more pleasurable, alive as individuals,

in the treatment center. It fits my notion of

what rehabilitation is all about.... We have

had a lot of problems with home dialysis. A

lot of it has to do with the effective dealing

131

with the family. We just don't know very much
about it. Unfortunately what happens with
people who are trained in nephrology--they
know very little about medical psychology or
liaison psychiatry, or however you want to
classify it; and as a result, people who are
trained at home to do things at home totally
screw up their family dynamics...: We've had a
number of people who have been on dialysis who
are divorced or separated. They just had to
stop because they were driving their spouse
away and their spouse goes on antique-buying
trips to just sort of get away from the city
while the person dialyzed himself. There
really are some enormous things we never
predicted were going to happen. I feel
inadequate to the task in spite of the fact it
is an area that I am very much interested
in..."

Although the movement to set quotas for the use
of given treatment modalities did not succeed, in 1983
the government adopted the composite capitation method
of payment, which rewards providers for adopting less
expensive treatment modalities, since they pocket the
savings realized by the adoption of those therapies.

Did physicians view such legislation, aimed at
influencing the content of their work, as effective?

Of renal physicians in the state, 62.96% agreed
that the legislation mandating capitation payment for
ESRD treatment had influenced the selection of treatment
modalities. Among all respondents, the tendency was to
indicate that composite capitation payments do influence
adoption of the less expensive therapies: that is, those
that are now most profitable to the treatment facility--

home hemodialysis and continuous ambulatory peritoneal

132

dialysis (see Table 6.13).

Since any savings realized from changing to less
expensive treatment modalities may be realized as profit
for the treatment facility, there will be no short-term
savings to the federal government from composite
capitation legislation. However, if less expensive
therapies come to predominate, renal physicians will
have a weakened basis for requesting increases in
reimbursement. Thus, long-term savings could result
from the introduction of composite capitation payments
for end-stage renal disease care.

Table 6.13. Physicians agreeing that

capitation payment favors use of named
treatment modality, 1987.

In-center hemodialysis 14.8%
Continuous cycling

peritoneal dialysis 19.8%
Transplant 28.3%
Home hemodialysis 37.0%
Continuous ambulatory 50.6%

peritoneal dialysis

Restriction of Renal Care Benefits

Another approach to reduce costs of the ESRD
program is to ration care, making it available to only
part of the ESRD population. "Rationing," a term that
raises specters of shortage and deprivation, has been
avoided in the United States. One nephrologist noted

133

"We call it 'restriction of benefits'; when other people
do it, we call it 'rationing.'" Rationing is common in
other nations: Great Britain denies hemodialysis to
patients who are over 65 and Sweden denies renal
transplantation to patients over 65 (Ruchlin, 1984).

The usual basis for rationing health care in the
Unites States is the fee: if individuals personally, or
through their insurance, cannot pay for medical care,
they cannot obtain it (Mechanic, 1978). This system is
harmonious with national notions that goods and service
should be distributed on the basis of equity rather than
equality. When the federal government set aside almost
all economic barriers to ESRD care, it sidestepped the
issue of whether there should be any limits on the
provision of ESRD care (Fox and Swazey, 1978).

Before the implementation of the federal ESRD
program in the state, private savings, private
foundations, private insurance, and privately-sponsored
fund-raising financed nearly all transplantation and
dialysis; cost-effective treatment was imperative.
Before 1973, the state had excluded some patients from
dialysis: people over 55, diabetics, and people unlikely
to benefit from treatment were denied dialysis in some
centers. In addition, because dialysands can have
asymptomatic serum hepatitis, some centers without

isolation rooms excluded drug addicts from treatment.

134

After 1973, the absence of national guidelines for
excluding patients from renal care meant that the state
could relax its own guidelines: however, a majority of
respondents favored continued limitations on eligibility

for renal care in both 1980 and 1987 (see Table 6.14).

Table 6.14. Physicians' approval of
limitations to eligibility for ESRD care.

1980 1987
Favor limits on 69.1% 71.8%
ESRD care
Favor limits based 63.2% 58.8%
on comorbidities
Favor limits based 42.6% 41.2%

on patient's age

Perhaps the development of continuous ambulatory
peritoneal dialysis, suitable for self-administration
even by blind diabetics, is responsible for the slight
decline in approval of limiting care based on
comorbidities. 'Respondent's attitudes on this issue
have been remarkably stable, perhaps because they derive
largely from personal ethics.

In open-ended responses made in 1987, forty of the
sixty-one physicians who agreed that benefits should be
restricted in some circumstances stipulated fifty-three
such circumstances. After content analysis, these
fifty-three circumstances have been grouped into seven
basic categories, shown in figure 6.15.

135

Table 6.15. Physicians' views on circumstances

warranting restriction of ESRD benefits.

General status--cited by eighteen physicians
Reflect concern with complete status of patient--
social, mental, and biological functioning: i.e.,
quality-of-life issues.

Physiologic status--cited by twelve physicians
Specify that limitation of ESRD care due to
comorbidity of patient should obtain only in the
case of advanced, widespread, or terminal disease.

Moral behavior of patients--cited by nine physicians
Includes such reasons as self-inflicted disease,
unrehabilitated I.V. drug abuser, murderer, lifer
in prison, drug dealer.

Mental status--cited by seven physicians
Specify limits for patients with dementia,
Alzheimer's.

Decision by patients--cited by three physicians
Take patients' expressed wishes not to suffer
longer into account.

Juutual decision--cited by three physicians
Express notion that decisions to limit care should
have input from physician, patient, and patient's
family or guardian.

Patient's autonomy--cited by one physician

Concern over whether patient's status permits
self-care.

136

Respondents' stress on patients' moral behavior
relates to both cause and treatment of renal disease:
Heroin use is associated with risk for sclerosing
glomerulonephritis (Zielezny, et al., 1980): thus,
heroin addicts are viewed as bringing renal disease on
themselves. Moreover, intravenous drug users with serum
hepatitis who are on hemodialysis may be asymptomatic:
thus, they put medical staff at risk for illness or
death from hepatitis.

Although about 70% of renal physicians supported
limitations on end-stage renal disease care, these
results should be interpreted cautiously. Gillick
(1988) reports that physicians engage in a complex
calculus in deciding whether to intervene aggressively
in patients' medical crises, and Wershow found "two out
of three [physician] respondents believe that the
physician has ultimate and sole responsibility for life
and death decisions" (1980:219). In light of renal
physicians' comments and other research findings, it
.seems likely that renal physicians' support for
restriction of benefits should not be construed as
interest in having a centralized agency set rigid
guidelines for rationing renal care.

How do the state's renal physicians evaluate the
quality of a renal disease program over which some

groups of physicians have wielded power? Their

137

assessment of the program's results yields an indirect
but detailed assessment of their views of the outcomes
of interest group liberalism (including a large share of
physician power) in policy making.
Physicians' Attitudes about Quality of Care

Many factors are important to the quality of care
patients receive in any system of health care. The
adequacy of medical lore, systems of referral, payment
mechanisms, social organization of the care delivery
system and the therapies used are among features that
make important contributions to quality of patient care.
Quality of Research

By 1980, while the United States was a center for
technological innovation in renal care, it attempted
little epidemiological or evaluation research. By
contrast, European nations were compiling international
records that permitted evaluations of ESRD treatment
modalities. One nephrologist questioned the research
done in the United States in university hospitals both
because of its highly selected (thus, nonrepresentative)
clientele as well as its technological focus:

"The research orientation in the medical

community at the present time is frankly-~I

think that we have a lot of research efforts

going in that area. To me, in terms of what

is needed from a society standpoint, is

epidemiological research. Research that goes

into issues that are other than, 'What's the

best way to deal with rejection?‘ Not that

that isn't an important issue. I think that

it is. But if we are going to take a look at

138

audit, let's take a look from a broad
epidemiological base. The university teaching
center is the worst place in the world to do
that.... What is frankly needed...is to begin
to involve every single community program that
you have...in a type of research effort which
takes a look at such issues as: relative
cost/benefits between types of treatment
programs: it looks at the use of alternative
personnel in end-stage renal disease. These
sorts of issues which are generally not
addressed in the typical reductionistic
research that goes on in your biomedical
research centers. And this is in no way to
demean the biomedical research center because
what they are doing is important and good and
all that. But it is to say that to limit
end-stage renal disease care to those
particular areas doesn't really address the
problem."

The above-cited nephrologist was part of an

articulate but small minority on this issue (see Table
6.16). Most renal physicians in the state agreed that
the United States has a superior level of knowledge and

research on transplantation and nephrology.

Table 6.16. Knowledge and research in renal
treatment in the United States compared to
other Western industrialized nations.

1980
Higher 83.8
Lower 5.9
Undecided/No Answer 10.3

State renal physicians' responses to this question
reflect both confidence in their knowledge base and
Preference for the clinical, biomedical, technology-
<Iriven medical knowledge that currently predominates in

139

the United States. Knowledge, however, is not
indicative of high-quality care unless it is translated
into practical action by the health-care delivery
system.

Primary Care

The federal end-stage renal disease program is not
integrated with the private primary system of health
care. The primary care system is an important source of
referrals to renal physicians, but one over which renal
physicians have no formally specified relationship or
power. In renal care, delayed referral is critical, as
conditions that might have been acute and reversible can
become chronic and irreversible if not treated promptly.
In addition, even chronic renal disease in its early
stages may be amenable to treatments that delay the
onset of end-stage renal disease.

In a time of perceived physician surplus,i
physicians who are specialists often allege that primary
care physicians "hold on" to their patients too long.
In their survey responses, renal physicians' agree late
referral is a problem in renal care (see Table 6.17).

Table 6.17. Agreement that renal patients are
referred in a timely manner.

1987
Agree 18.8%
Disagree 70.0%
Undecided/No Answer 11.3%

140

Delay in referral, if as extensive as perceived, is
not only reducing quality of renal care but also adding
to costs of renal treatment. Such losses of efficiency
seem inevitable in categorical programs like the end-
stage renal disease program that separate treatment-
oriented approaches from preventive care.

Government Involvement in Renal Care

In the United States, government-funded health care
is popularly viewed as equalizing access to care but
jeopardizing quality of care, especially if it
interferes too much with "market" forces (Alford, 1972).
For example, about two thirds of physician respondents
to Hendricks and Carlova's survey (1971) believed
national health insurance would worsen quality of care.
The results of this study tend to echo Hendricks and
Carlova's findings, with physicians indicating that less
government in ESRD care would improve service delivery

(see Table 6.18).

Table 6.18. Less government involvement in
renal disease would improve service delivery.

1980 1987
Agree 63.2% 52.9%
Disagree 26.5% 36.5%
Undecided/ 10.3% 10.6%

NC Answer

In 1987, the declining number of respondents who
believe the government has a negative impact on service

141

delivery may reflect an increasing awareness that the
ESRD program would function at a greatly reduced level
if government financial support of the program were
withdrawn.
Access To Care

Between 1980 and 1987, agreement that the ESRD
program made adequate services available to patients had
decreased by almost 20% (see Table 6.19). It seems
probable that declining levels of agreement that
adequate services are available has to do with cost
constraints on the renal program, introduced by the
federal government and implemented by the insurance
carrier.

Table 6.19. The supply of ESRD services is

sufficient to guarantee that patients will
receive adequate medical care.

1980 1987
Agree 95.6 78.8
Disagree . 1.5 17.6
Undecided/ 3.0 3.5

No Answer

Effects of Cost Containment Measures

Previous research has found physicians unfavorable
to cost-containment measures: According to Hendricks and
Carlova, 69% of physicians they surveyed found
capitation payment "unacceptable" (1971:82). Kwon and
Volger (1985) also found that about two-thirds of
physicians disagreed that consumers would benefit from

142

legislation limiting length of hospital stay on the
basis of illness (diagnosis-related groups). Relatively
high rates or eezeene for capitation payment and
relative ease in obtaining exceptions to the screens
helped make capitation payment more palatable to renal
physicians when the ESRD program began. Between 1980
and 1987, DRG's and composite capitation rates had been
implemented to curtail costs of the ESRD program.
Composite capitation meant that the physician received
the same rate of reimbursement, regardless of the cost
of the therapy employed.

Few renal physicians (see Table 6.20), viewed the
effects of the composite capitation payment mechanism on
quality of care positively, a large minority were
undecided, and almost half viewed the effects
negatively.

Table 6.20. The effect of capitation payment
on services to patients, 1987.

Positive 19.3%
Undecided 33.7%
Negative 47.0%

Among those respondents attributing the declining
adequacy of care to cost constraints, many added

commentary:

"...politicians promise many things to the
people, but when they cannot fund adequate
programs they shift the blame to the providers
of care and then decrease funding to
eventually force second-rate care...."

143

"It is difficult to give accepted forms of
medical care because of lack of reimbursement
(i.e., Desterol for aluminum overload)."
"'DRG's' force me not to hospitalize sick
people and if they are hospitalized, I have to
discharge them too soon or I am unable to do
all the necessary tests."

"Non-payment for acute dialysis and other
arbitrary government regulations are choking
quality care."

"Carrier has, by stopping and cutting payments,
started to reduce availability of care."

Pruchansky has argued that such responses are
typical in the history of medicine in the United States:
"...the spokespeople for medical associations frequently
predicted a decline in the quality of care as a response
to any perceived threat to physician dominance of the
health care sector" (1983:513). From the quotations
above, however, it is likely that renal physicians'
opposition to cost control measures is driven by some
degree of concern for their patients' welfare.

Renal physicians' dubiousness about the influence
of composite capitation payment on patient care is
nearly equaled by their dubiousness about the influence
of proprietary corporations on patient care (see Table

6.21).

Table 6.21. Effect of proprietary
corporations on services to patients, 1987.

Positive 19.0%

Undecided 36.9%
Negative 44.0%

144

This result may reflect a belief that proprietary
dialysis facilities engage in a practice known as
"skimming and dumping." If those cream-of—the-crop
patients who are the least expensive to treat are
skimmed by profit-making centers, other facilities must
absorb the costs of treating sicker patients who are
"dumped" into their facilities because the for-profit
centers are not equipped to handle them. Proprietary
facilities, able to get rid of their sicker patients,
have no motivation to engage in rehabilitation or
prevention, according to the logic of those who charge
them with the practice.

Treatment Modality Mix

In-center hemodialysis has been the predominant
ESRD treatment modality in the state. It is the most
expensive of the treatment modalities, and more
utilization of transplantation or home dialysis would
reduce the costs of the ESRD program. In both 1980 and
1987 (see Table 6.22) the majority of physicians

indicated that they would prefer a change in treatment

modality mix.

Table 6.22. Physicians favoring more use of
the named treatment modality.

1980 1987
Transplant 80.9% 90.6%
Home HD 92.7% 78.8%
CAPD NA 88.3%

145

Physicians appear to view current modality mix as
suboptimal. Renal physicians' preference for transplant
cannot be realized, because of the scarcity of cadaveric
donor organs and because of physicians' reluctance to
use living-related-donor transplants. However, greater
use of either peritoneal dialysis or home hemodialysis
has been accomplished in Great Britain and in the state
of Washington and presumably could be accomplished
elsewhere.

Even in 1980, when reimbursement structures
provided disincentives to home hemodialysis, most
respondents agreed that it should be adopted more
frequently. Therefore, the large number of respondents
in 1987 who favored more home dialysis cannot be
attributed entirely to changes in the incentive
system that made home dialysis the most profitable
therapy for physicians to administer. Some of the
popularity of peritoneal dialysis was based on clinical
experience, as this nephrologist attests:

"[patients on peritoneal dialysis had a]

general sense of well-being that was better.

And part of the "better" was that it

biologically was better. There weren't the

ups and downs, and you were constantly

dialyzing the middle molecule all of the time.

You were getting rid of the things that you

weren't doing a good job with [on]

intermittent hemo."

Whatever the cost-saving effects of composite

capitation payments may be, survey respondents are

146

divided about whether it is having the effect of
changing treatment modality mix in a desirable direction
(see Table 6.23). Thus, composite capitation payment is
viewed as only marginally effective in achieving what
respondents view as the optimum treatment modality mix.

Table 6.23. Effects of capitation on quality

of treatment modality mix, 1987.

Transplant Home HD CAPD

Physicians 90.59% 78.82% 88.23%

favoring (n=77) (n=67) (n=75)

more use of a

treatment

modality.

Physicians 29.87% 44.78% 57.33%

believing (n=23) (n=30) (n=43)

capitation
payment

encourages
use of the
modality they
favor.
ESRD Program as Model for Other Programs
The enactment of Public Law 92-603 by the United'
States Congress enabled federally-funded provision of
80% of dialysis or renal transplant costs to nearly all
persons suffering end-stage renal disease. However, as
more attention was focused on costliness of the ESRD
program, notions that it might serve as a model for
other catastrophic disease programs received less
attention. Respondents in the state were almost evenly

divided in their assessment of the ESRD program as a

147

demonstration project (see Table 6.24).

Table 6.24. The ESRD program is a good model
for other catastrophic disease programs.

1987
Agree ‘ 45.9%
Disagree 47.9%
Undecided/No Answer 7.1%

One supporter of the ESRD program referred to it as
a "grand experiment." The favorable comments of other
renal physicians have been organized into general
themes, presented in Table 6.25. These are derived from
content analysis of renal physician' comments to open-
ended questions in the 1987 survey. It should be noted
that these favorable comments are all confined to
characteristics of the state program and the people
working in it and not to the role of the federal
government in the program.

Even a critic of the ESRD program recognized its
potential, remarking, "The federal government made a
sad, expensive mess of an unparalleled opportunity." In
both surveys and interviews, negative commentary of
renal physicians and program officials in the state
emphasized the irrationality of numerous federal

practices, as summarized in Table 6.26.

148

Table 6.25. Physicians' positive comments
about end-stage renal disease care in the
state.

Ready access to care and choice of treatment
. modalities: 17 comments.

Provider and local agency communication and
cooperation: 17 comments.

High quality of professionals, facilities,
and care: 10 comments.

Table 6.26. Physicians' negative comments about
end-stage renal disease care in the state.

Bureaucratic procedures in government and
insurance agencies. Criticisms of waste, red
tape, irrationality of rules, failure to
control costs without damaging quality of
care: 40 comments.

Concerns with access to care and quality of
care. Criticism of "dialyzing for dollars" by
proprietary facilities, concern about distance
to treatment facilities for patients in rural
areas, and concern about the effects of cost
constraints: 18 comments.

Failure to arrive at consensus about
restriction of benefits (a minor cost-
contraint measure): 7 comments.

Physician and facility greed and profit
motivation: 3 comments.

Government control: 1 comment.

149

A more detailed examination of renal physicians'
evaluation of the end-stage renal disease program as a
model for other catastrophic disease programs, taken
both from answers to open-ended questions and from
interviews, follows.

Boundary Problems

The federal government's mandate that the end-
stage renal disease program be regionalized assured a
heterogeneous nation-wide non-system of renal care.
Said a nephrologist, "The same guy planned it that
planned Iranscam." Appointing numerous agencies to
carry out the program created what another physician
called a "bureaucratic quagmire" (Riska, 1985).

In addition, boundaries for regions were drawn
disregarding state boundaries and the cognitive mapping
of "catchment areas" that had occurred before 1973.

In the state, regional boundaries are almost identical
to state lines. Thus, the Network Council has dealt
with only one series of state agencies. However, the
state had to fight to keep one area of the state within
the regional Network, and renal physicians were keenly
aware of the absurdities involved in setting the
boundaries in other regions.
Payment mechanisms

Reimbursement was another issue on which physicians

criticized the government's ineptness. For example,

150

there were no codes for transplantation work and
vascular access work, which instead were conducted on a
cost-plus basis. According to one transplant surgeon:

"I may put in a charge of $500.00 for doing a
vascular graft between two places (from
arteries to veins), and spend about two-and-a-
half or three hours doing an operation, and
submit a bill for $500.00 and they'll pay me
$200.00. They don't know what I'm talking
about. We submit opnotes, but there are no
codes....There is such a heavy bureaucracy
that nobody knows what's going on there.
That's the bad thing about government in
medicine. That is very, very bad. Inertia

is terrible. Everybody is so busy
protecting...their own hind quarters that
they don't think about really getting in there
and getting the job done."

In 1987, per dialysis reimbursement was $212 in
major metropolitan regions, $162 in smaller cities, and
$132 in rural regions, a scheme that non-metropolitan
physicians regarded as unfair.

To avoid setting up a duplicate bureaucracy, the
federal government mandated that private insurance
carriers, appointed in each region, should act as
intermediaries. Unpopular as most "middle men," the
insurance intermediary was viewed in a highly
uncomplimentary light:

"[insurance intermediaries are] doing their

best, with their dated, high-school, computer

mentality to reduce costs by driving doctors

out of state--at which they continue to be
successful."

"Inefficient, ignorant, carrier."

"Reimbursement system [of the carrier] has been
poor."

151

'I [ £~'-li‘_:4.o

"...intermediary is obstructive, unresponsive
arbitrary and inefficient. I'm leaving [the
state] in large part for the above reasons."

In addition, renal physicians criticized Medicare as
an inappropriate mechanism for dealing with catastrophic
illness, because deductibles and co-insurance
requirements that are part of the Medicare program
penalize the person with the disease.

Inadequate Data for Decisions

In the view of one nephrologist, regional data-
gathering activity should have provided a model for the
national end—stage renal disease database:

"If you really want a good program on the

national level, dammit get a good data set so

that you can analyze it effectively."

An informed basis of decision-making about closing
transplant facilities would have taken into account
geographic distance, population distribution, and the
different centers' morbidity and mortalilty statistics.
Instead, the government adopted a Social Darwinist
model in its attempt to reduce numbers of transplant
facilities. According to an agency official, a numeric
quota for transplants was the sole criterion for the
facility's worthiness to survive:

"...the federal regulation picked out this

magic number--fifteen--for transplants, which

has never been substantiated....And now I

think that Health, Education and Welfare is

even getting a little scared over enforcing

this, because of not really knowing the facts
of this number."

152

A transplant surgeon adds:

"...it was assumed when the federal guidelines

were drawn up that the more transplants, the

better you were: the more experience you had,

the better your results would be.... But this

has not really been brought out. Well-run

community centers have graft survivals, patient

survivals, morbidity statistics that are quite
comparable with most university centers."
Conclusions

The results reported in this chapter for renal
physicians tend to support Goldman's notion that many
physicians in the United States are not as conservative
as they are sometimes portrayed. As specialists,
particularly as specialists whose prestige and incomes
were enhanced by a federal program, renal physicians
might have been expected to be more liberal than many
other groups of physicians in the United States. This
is not to argue that these renal physicians' opinions
place them in a radical forefront of United States
physicians. Rather, these results suggest a complex
portrait of renal physicians' policy attitudes.

For example, in 1980 and 1987, a majority believed
government regulation of the ESRD program was important
and would have granted consumers more voice in setting
ESRD policy. In 1980, nearly all preferred medical
professional planning and administration of the program.
I believe these findings are not necessarily in conflict
with one another, but involve what Freidson views as the

essence of professionalism--the degree to which

153

physicians perceive that their freedom to determine the
content of medical work (diagnosis, prescription or
treatment, and evaluation of work by colleagues) is
preserved. The fact that only about one-third would
give patients more influence in selection of treatment
modality tends to support this notion that the more the
activity of an outsider or outside agency threatens the
physician's autonomy in content of work, the less
favorable will the physician be to that activity. Their
view government as more threatening to their autonomy
than corporations supports assertions Starr (1982) has
made about their political views.

Cost containment in the ESRD program has been a
central issue for Congress and government agencies.
Among proposed cost-reduction measures, a majority of
renal physicians favored regionalization of transplant
facilities and restriction of benefits to patients. A
substantial minority favored restricting practitioners'
entry into ESRD care by the certificate of need.
However, these responses should not be interpreted to
indicate that renal physicians believe the government
should make decisions on any of these issues. In fact,
the renal physicians regarded the government's composite
capitation payment mechanism as only marginally
successful in bringing about a change toward adoption of

less expensive treatment modalities.

154

Physicians' reluctance to have outside agencies
make and enforce policy is evident in their criticisms
of government and insurance company bureaucracy. It
should be noted that their focus is on bureaucracy and
not on socialized medicine or on the political and
economic arrangements underlying health care problems in
the United States. Their reactions to the federal renal
care program often appear to be issue-specific and
grounded in their concrete experiences with the program
rather than grounded in political values.

It could be argued that renal physicians' views
that the government is generally inept, having brought
on declining quality of care and having made numerous
questionable decisions is a rhetorical smoke screen,
disguising the place of renal physicians' power and
profiteering in creating problems in the ESRD program.
Riska (1985) has argued that decentralized, pluralistic
medical systems obscure responsibility and prevent
consumers from identifying social causes of their
problems. Perhaps some physicians are disingenuous in
their criticisms of the ESRD program, it seems equally
likely that renal physicians, like consumers, have
trouble attributing responsibility when dealing with the
multiple agencies that administer the ESRD program.

In this chapter, renal physicians' views on their

autonomy, on policy that might restrict their autonomy,

155

and on the quality of the program they have shaped have
been reviewed. In the following chapter, the notion of
Freidson, Colombotos, and others that sociological
variables are related to physicians' attitudes will be

explored.

156

A DOUBLE-EDGED SWORD:
PHYSICIANS' VIEWS OF THE END-STAGE RENAL DISEASE PROGRAM

Volume II
by
Nancy Louise Buffenbarger
A DISSERTATION
Submitted to
Michigan State University

in partial fulfillment of the requirements
' for the degree of

DOCTOR OF PHILOSOPHY
Department of Sociology

1990

Chapter 7
Correlates of Physician Attitudes

For much of this century, the American Medical
Association was viewed as representing the opinions of
all American physicians in its pronouncements on the
correct relationship between government and medicine.
AMA pronouncements generally foretold that national
health insurance, or other federal meddling in health
care, would be the first step to national socialism
(Riska, 1985). However, in the 1960's and 1970's,
proposals for restructuring delivery of health care,
many of which involved federal finance or intervention,
prompted less elitist approaches to understanding
practicing physicians' attitudes to greater federal
intervention in the health care system.

Studies of the attitudes of practicing physicians
raised questions about the representativeness of the
policy statements made by the "organized medicine lobby"
(Goldman, 1974b:177). For example, despite fierce
opposition to Medicare by the AMA, Colombotos (1969)
found 38% of physicians in New York State favorable to
Medicare, even before passage of the enabling
legislation. Later, Colombotos et al., (1975), in a
national study of physicians, found the majority (56%)
in favor of National Health Insurance. Upon obtaining

similar results in his studies of Yale-educated

157

physicians, Goldman concluded "...a large minority [of
physicians]...are not represented by the AMA's official
party line" (1974a:421).

Characteristics of Physicians and Medical Practices

Colombotos', Goldman's and similar studies indicate
that certain characteristics of physicians or their work
may be associated with their attitudes about issues in
medical care. Eliot Freidson (1975) has argued that the
structure of a medical practice tends to cast the
physician into certain roles--craftsman, bureaucrat, or
entrepreneur--and that these roles are important
influences on physicians' attitudes and behavior. The
present study sought confirmation of the notion that
practice setting and physicians' social characteristics
are related to their attitudes.
Political Attitudes
Prior research findings support the idea that

physicians who are self-identified as politically
liberal tend to be liberal on medical issues. For
example, liberal political attitudes of physicians have
been associated with more favorable attitudes to
Medicare (Colombotos, 1968), more favorable attitudes to
National Health Insurance, (Colombotos, et al., 1975),
more receptiveness to general innovations in health care
delivery (Mechanic, 1974), and more openness to specific

innovations such as capitation payment (Goldman, 1974a)

158

and certificate-of-need legislation (Pruchansky, 1983).
Results of the current study lend support to the
notion of a relationship between physicians' political
orientation and their medical policy attitudes
on such issues as government involvement in the ESRD
program, government regulation of the ESRD program and
regionalization of transplant facilities (see Table
7.1). In sum, political liberals were more favorable
than others to various aspects of government involvement
in the ESRD program. In addition, the only renal
physicians who believed medical professionals should D2:
plan the ESRD program were political liberals. Both
liberal and conservative physicians were significantly
more likely than were political moderates to agree that
renal physicians actually gig influence end-stage-renal-
disease program policies, perhaps because groups at
either end of the political spectrum were more likely to
be strongly invested in policy issues and sensitive to
the influence they or their opponents had exercised in
various power struggles. Because of the small numbers
of both liberal and conservative physicians, these
results must be interpreted cautiously, but they tend to
support earlier findings of an association between
political and medical liberalism. Because-of the small
numbers of politically conservative and liberal renal

physicians, their politics were not identified in 1987.

159

Table 7.1. Physicians' self-identified
politics and medical policy attitudes, 1980.

Conservative Moderate Liberal
(n=15) (n=34) (n=13)

Agree 6.7% 27.3% 53.8%
government

involvement in

renal care is

positive for

services to

patients.

(p:.0210)#

Favor 26.7% 48.5% 84.6%
government

regulation of

renal care.

(9:.0086)

Favor 26.7% 59.4% 69.2%
transplant

facility

regionalization.

(p=.0480)

Favor 100.0% 100.0% 75.0%
professional

planning of

ESRD program.

(p=.0018)#

Agree renal 50.0% 20.0% 50.0%
physicians are

influential in

ESRD policy.

(p=.0477)#

# Expected frequency <5 for at least one cell.

160

Country of Medical Education

Medical education in the United States is
believed to be asSociated with conservative attitudes
because of the extreme emphasis placed on medicine as a
market commodity in the United States. Colombotos et
al., (1975) found foreign-educated physicians more
favorable to national health insurance than were U.S.-
educated physicians. He argued that, while these
physicians were probably more conservative than their
peers who remained in the country of origin, their stays
in the United States had not yet socialized them to be
as conservative as U.S.-educated physicians.

In the current study, renal physicians educated'
abroad were more favorable to consumer involvement in
planning renal policy than those educated in the United
States (see Table 7.2). Findings were in the same
direction but not significant at the p=.05 level in
1980. Respondents educated in the United States were
significantly more likely than those educated abroad to
agree in 1987, but not in 1980, that patients should
have more influence in selecting treatment modalities,
perhaps responding to recent concerns of malpractice
insurers that patients have given "informed consent" to
their treatment. The findings for 1987 suggest that
while renal physicians educated in the United States

were more favorable to interpersonal democracy in

161

therapy selection, renal physicians educated abroad were
more favorable to macropolitical democracy in health
care issues, perhaps because citizen participation in
health policy decision-making is more common in the
nations where many were educated.

In 1980, renal physicians educated in the United
States were more likely than those educated abroad to
agree that they had been influential in shaping regional
renal policy. The greater belief in their political
effectiveness among U.S.-educated renal physicians
perhaps reflects an "American" belief that interest-

groups are an effective way to make social policy.

Table 7.2. Significant relationships between
medical education and dependent variables.

Educated Educated
in U.S. abroad
(1980 n=45) (1980 n=21)
(1987 n=51) (1987 n=3l)

Favor increased

consumer

involvement in

ESRD policy.

1980 ps.ll73 48.8% 70.0%

1987 2?.0178 65.2% 89.7%

Patient should have

more influence in

therapy selection.

1980 p=.5892 ' 40.5% 48.0%
1987 2?.0470 47.6% 25.8%

Renal physicians

are influential

in ESRD policy.

1980 EF-0099 43.6% 6.7%
1987 NA NA

162

Specialty

Surgeons, as elite specialists in an elite
profession, are believed to have much at stake in
preserving a system that has provided them with high
status and incomes. Some research findings support the
vision of surgeons as conservative supporters of the
status quo. Goldman found surgeons more conservative
than other specialists on national health policy issues
(1974) and political issues (Goldman and Ebbert, 1973),
and Colombotos (1968) found surgeons the specialists
least supportive of Medicare and National Health
Insurance (Colombotos et al., 1975). These findings,
together with the remarks of an agency official in the
state, suggested that transplant surgeons would be more
conservative than other renal physicians:

"...when the Medicare program was already

looming on the horizon in '72, their answer--

being typical surgeons--was, 'Well, just

ignore it, and it will go away': and, of

course, it didn't go away, and they finally

realized they, you know, had to join the

Network. They had to participate if they

wanted to get reimbursed. But they all

objected. I mean, they were all writing

letters to their Congressmen: They didn't

want this socialized medicine."

In my study, transplant surgeons' 1980 reactions to
government regulation of the ESRD program (see Table
7.3) tended to support the notion of surgeons'

conservatism, with 23.1% favoring government regulation

compared to 60.0% of nephrologists.

163

Table 7.3. Significant relationships between
medical specialty and dependent variables.

Nephrologist Transplant
Surgeon

(1980 n=47) (1980 n=13)
(1987 n=67) (1987 n=1l)

Transplant

facilities

should be

regionalized.

1980 p=.0157 68.2% 30.8%

1987 p=.0580# 73.8% 45.5%

Government should
regulate ESRD

program.
1980 2=.0189 60.0% 23.1%
1987 Q=.1589# 56.5% 80.0%

Nephrologist has

most influence on

treatment decision.

1980 p=.2158# 76.7% 92.3%
1987 2?.0235# 66.7 100.0

Surgeon should have

more influence on

therapy selection.

1980 Q=.0106# 7.0% 38.5%
1987 NA NA

Capitation affects

choice of therapy.

1980 NA NA
1987 Q;.O476# 60.0% 90.9%

# Expected frequency <5 for at least one cell.

164

However, by 1987, 80.0% of transplant surgeons were
favorable to government regulation of the renal disease
program, compared to 56.5% of nephrologists.

Between 1980 and 1987, nephrologists' incomes and
autonomy were more threatened by new regulations than
transplant surgeons': probably nephrologists'
perceptions of increased federal stringency accounts for
the slight decline in their support for government
regulation. During this time, surgeons' support for
federal regulation of the ESRD program increased,
perhaps because they viewed the brunt of new regulations
as falling on nephrologists.

In 1980, nephrologists were significantly more
likely than transplant surgeons to favor regionalization
of kidney transplant facilities rather than their "free-
market" growth, another indication of greater
conservatism among surgeons. In 1987 findings were in
the same direction but not significant at the p=.05
level. In 1980, there was great uncertainty about which
transplant facilities were in jeopardy of being closed,
and transplant surgeons' jobs were directly affected by
this threat. By 1987, it was felt that remaining
transplant facilities would stay open. This change
probably accounts for decreased opposition to
regionalization of transplant facilities among

transplant surgeons.

165

In 1987, perhaps reflecting inter-specialty
rivalries, transplant surgeons were significantly more
likely than nephrologists to agree that nephrologists
have the most influence in the choice of treatment
modalities for ESRD patients. In 1980, too, surgeons
were more likely than nephrologists to agree that
nephrologists are most influential in selection of
therapy, but the differences were not significant at the
p=.05 level. The present referral system, from
nephrologist to transplant surgeon, is probably the
basis of the transplant surgeons' attribution of
therapy-selection power to nephrologists. In 1980,
surgeons were significantly more likely than were
nephrologists to agree that the surgeon should have more
influence on the selection of treatment modality.
Nephrologists, for their part, argued that anticipated
improvements in survival of transplanted kidneys had not
come about and that many patients were better off
remaining on dialysis than going through a graft
rejection. It should be noted that most of these
arguments were made in the absence of sophisticated
statistical analysis of types of patients most likely to
do well on transplant.

In 1987, transplant surgeons were significantly
more likely than nephrologists to agree that changes in

the system of capitation payments had influenced the

166

selection of therapy. Perhaps this finding reflects
nephrologists' view of themselves as altruists, helping
patients to select optimal therapies based on their
medical conditions, while surgeons took the more
jaundiced view that therapy selection is partially
guided by nephrologists' considerations of its impact on
their incomes. In conclusion, these findings suggest
that specialists' views are related to group-specific
vested interests on each issue, with transplant surgeons
often, but not always, more conservative than other
renal specialists. However, all the findings in this
section are based on responses from small numbers of
transplant surgeons and must be interpreted cautiously.
Attendance at Professional Meetings

Attendance of professional meetings is a source
ongoing socialization. Some meetings are concerned
primarily with political action, others with health
policy, and still others with continuing education and
research. Respondents commented that they attend
professional meetings for varied reasons: 1) belief that
interest groups should articulate advisory opinions and
local policy decisions: 2) desire to protect vested
interests, despite some cynicism about the efficiency
and effectiveness of interest-group activity; 3) the
wish to obtain information or establish consensus about

treatment and policy questions. In the state, the

167

percentage of renal physicians who attended five or more
meetings a year declined between 1980 and 1987.

In 1980 renal physicians who attended five or more
meetings were significantly more likely than others to
favor excluding patients from renal care based on their
ages (see Table 7.4). Before the federal ESRD program
was implemented, some facilities in the state had
established age-based restrictions on renal care.
Perhaps professional meetings provided a forum for
physicians to reach consensus about situations in which
access to care should be limited, although the federal
program did not require them to do so.

By 1987, the relationship between meeting
attendance and favoring age limits on ESRD care no
longer existed. Perhaps the development of peritoneal
dialysis, which enabled many elderly people to conduct
less-expensive home dialysis is one of the reasons for
this change.

In 1987, renal physicians attending five or more
meetings a year were significantly less likely than low-
attenders to view the government as limiting physicians'
autonomy. Similarly, physicians who attended more
meetings were significantly less likely than low-
attenders to believe that corporations limit physician

autonomy.

168

Table 7.4. Relationships between physicians'
attending professional meetings and dependent
variables.

Five or Four or
more fewer
meetings meetings

(1980 n=24) (1980 n=43)
(1987 n=24) (1987 n=59)

Believe supply

of ESRD care

is adequate.

1980 33.4462# 100.0% 97.6%
1987 98.0492# 95.7% 77.2%

Age should limit
eligibility for

ESRD care.
1980 2!.0216 62.5% 33.3%
1987 93.9338 41.7% 40.7%

Government limits
renal physician

autonomy.
1980 NA NA
1987 p=.0085 45.8% 75.9%

Large corporations
limit physicians'

autonomy.,
1980 NA NA
1987 9;.0056 25.0% 62.6%

ESRD knowledge

in the U.S.

superior to

that abroad.

1980 ps.0059# 81.8% 100.0%
1987 NA NA

Medical professionals
should plan ESRD

program.
1980 2?.0205# 87.5% 100.0%
1987 NA NA

# Expected frequency <5 for at least one cell.

169

This result suggests that renal physicians who
attend more meetings perceive collective action as
effective in deflecting corporate and government
incursions on their autonomy. Conversely, perhaps those
who attend fewer meetings are more dubious about the
effectiveness of professional collective action.

Renal physicians attending five or more meetings a
year were more likely to agree in 1987 that the supply
of renal care in the region is adequate than those
attending fewer professional meetings. This last
finding, together with that on autonomy, indicates that
renal physicians attending more professional meetings
are somewhat more satisfied with the overall results of
the current renal disease program than are renal
physicians who attend fewer professional meetings.

In 1980, physicians attending more meetings were
significantly less likely than others to believe end-
stage renal disease knowledge in the United States is
superior to that in other nations and they were less
likely to agree that medical professionals should plan
the end-stage renal disease program. Thus, renal
physicians attending five or more meetings appeared
somewhat more skeptical about the superiority of medical
professional knowledge and planning than were renal

physicians attending fewer meetings.

170

Professional Organization Membership

Membership in professional organizations provides
ongoing professional socialization of renal physicians
through such direct means as meeting attendance and
through such indirect means as newsletters and journals.
Membership in many renal physician organizations
indicates at least passive interest in a wide variety of
issues of concern to renal physicians. Mechanic
(1974) found physicians who were members of local
medical societies more liberal in that they were more
receptive to innovations in health-care delivery than
were non-members.

In the present study, in 1980 renal physicians with
five or more memberships in professional organizations
were significantly more likely to agree that renal
physicians are influential in setting renal policy in
the region than were those with fewer memberships (see
Table 7.5), perhaps indicating a belief in the efficacy
of interest group liberalism. In 1980 renal physicians
with memberships in five or more renal physician
organizations were also significantly more likely to
agree that patients should have more influence in the
choice of treatment modality, an issue of interpersonal

democracy, than were those with fewer memberships.

171

Table 7.5. Memberships and dependent variable
relationships.

Five plus Four or fewer
(1980 n=37) (1980 n=30)
(1987 n=17) (1987 n=62)

Renal physicians

are influential

in setting policy.

1980 Q=.0372 45.5% 18.2%

1987 NA NA

Patient should have

more influence in

therapy selection.

1980 Q=.0077 58.3% 25.0%

1987 93.6998 41.2% 36.1%

Nephrologist should

have more influence

in therapy selection.

1980 p;.0293# 5.6% 24.1%

1987 NA NA

# Expected frequency <5 for at least one cell.

A final significant difference in 1980 was that
low-membership renal physicians were more likely than
high-membership renal physicians to agree that the
nephrologist should have more influence in therapy
selection. In summary, in 1980 belonging to many
professional groups was associated with an apparent
acceptance of a generally liberal stance on some issues:
agreement that renal physician advisory input on policy
matters is effective; willingness to extend democratic
decision-making to the issue of patient therapy choice:
and less support for increasing the nephrologist's

dominance in therapy selection. For the sake of

172

questionnaire brevity, the questions in renal
physicians' policy influence and nephrologists' ideal
influence on therapy selection were omitted from the
1987 survey. By 1987, the attitudes of high-membership
and low-membership renal physicians on the issue of
patient influence in therapy selection had converged.
This convergence is perhaps explained by responses to
another question.

Between 1980 and 1987, all respondents viewed
nephrologists as losing some influence in therapy
selection: while 76.5% viewed them as most influential
in 1980, this fell to 69.4% in 1987. During this time,
patients were viewed as increasing their influence, with
8% viewed as most influential in therapy selection in
1980 and 17.6% viewed as most influential in 1987 (see
Table 6.8). Perhaps renal physicians viewed the balance
of power between physicians and patients as having
shifted far enough, and this is the reason for the
convergence of opinion between high- and low-membership
physicians.

Physician's Age and Career Stage

Prior findings on the relationship between
physicians' ages or career stages and their attitudes on
issues in medical care are not definitive. Colombotos
(1968) found older physicians more favorable to Medicare

than were younger physicians. In addition, Goldman and

173

Ebberts found no support for the notion that age begets
conservatism in their 1973 study of Yale medical
graduates (Goldman, 1974a). In fact, Goldman found
younger doctors to be leee "reform-minded" on issues of
medical politics than were older physicians (1974a:420).
However, Colombotos et al. found house staff more
receptive than more-experienced physicians to National
Health Insurance (1975). In addition, Mechanic (1974)
found physicians who had practiced fewer years more
receptive to innovations in health delivery than were
more-experienced physicians. Hendricks and Carlova
(1971) found physicians over 50 most resistant to
National Health Insurance. A study by California's
Bureau of Research and Planning found that physicians
who were graduates and residents were more conservative
on several health-care issues than were medical school
seniors, who, in turn, were more conservative than
medical school freshmen (California Medicine, 1969).
Finally, Herman found that as medical students progressed
through school, they moved toward "traditional
[conservative] physician attitudes" (1984:204).

In the 1987 survey, respondents who had practiced
less than seven years were more likely to agree that
end-stage-renal-disease patients should have more
influence in selecting their own treatment modalities

than were more experienced physicians (see Table 7.6).

174

Table 7.6. Significant relationships between
years of practice and dependent variables.

Seven or Eight or
' fewer more
(1980 n=3l) (1980 n=37)
(1987 n=20) (1987 n=63)
Patient should have
more influence in
therapy selection.
1980 2?.2833 50.0% 36.7%
1987 93.0270. 60.0% 32.3%
ESRD network should
have more influence
in setting policy.
1980 Q=.0108# 12.0% 34.4%
1987 NA NA

# Expected frequency <5 for at least one cell.

In 1980, differences between more- and less-experienced
renal physicians on this issue were in the same .
direction but not significant at the p:.05 level. The
recently-trained renal physicians' greater support for
higher levels of patient influence in treatment modality
selection might reflect the success of medical schools'
recent efforts to train physicians to engage in more
egalitarian relationships with patients and greater
receptiveness to malpractice insurers' pressures for
informed consent. However, this finding might also
reflect more-experienced renal physicians' confidence in
their own medical judgment and socialization in the
practice setting into a less democratic decision-making
style.

In 1980, more—experienced renal physicians were

175

more likely than were less-experienced renal physicians
to agree that the end-stage renal disease network should
have more influence in setting policy. These findings
indicate that on issues of therapy selection and policy
making older physicians were more likely than younger
physicians to emphasize their own autonomy.

In 1980, the physicians' age was associated with
one dependent variable, with renal physicians under age
forty-five more likely to favor the regionalization of
renal transplant facilities than were renal physicians
over age 45 (see Table 7.7). By 1987, the difference
between older and younger renal physicians was no longer
significant, perhaps because there was a sense that more
closing of transplant facilities was unlikely.

Table 7.7. Significant relationship between

physician's age and dependent variable.

45 or Less than
older 45

(1980 n=20) (1980 n=48)

(1987 n=33) (1987 n=48)
Transplant

facilities
should be
regionalized.
1980 33.0080 31.6% 67.4%
1987 23.3641 [65.6% 75.0%
Structure of Medical Practice
Metropolitan or Outstate Location of Practice
In New York, Colombotos (1968) found metropolitan

physicians more favorable to Medicare than suburban

176

physicians, who, in turn, were more favorable than
upstate physicians. Mechanic (1974) found physicians
from larger communities more open than physicians in
smaller communities to innovations in health care
delivery.

In studying renal physicians, there is further
reason to preserve the rural-urban distinction in the
form of Metropolitan and Outstate categories: The
federal government's reimbursement scheme paid
Metropolitan-area renal physicians higher rates than
those in smaller cities and rural areas, creating and
reinforcing distinctions among renal physicians. In
their comments, both smaller city and rural physicians
described the reimbursement differentials as unfair.
Because of this and because of the small numbers that
would have resulted had I separated smaller city from
rural renal physicians, smaller city and rural
physicians were placed in a single analytic category.
(It should be noted that the renal program's definitions
of metropolitan, city, and rural areas do not coincide
with census definitions of these categories.) In the
current study, Metropolitan renal physicians in 1980
were more likely than those from Outstate areas to agree
interest-group liberalism had been effective, in their
agreement that renal physicians had been influential in

shaping renal-care policy in the region (see Table 7.8).

177

Table 7.8. Significant relationships between
location of practice and dependent variables.

Metropolitan Outstate
practice practice
(1980 n=33) (1930 n=32)
(1987 n=45) (1987 n=39)

Renal physicians

are influential in

setting policy.

1980 Q3.0023 55.6% 15.4%
1987 NA NA

ESRD knowledge in
the U.S. superior
to that abroad.

1980 p=.0241# 85.2% 100.0%
Favor more home

hemodialysis.

1980 p=.0760 100.0% 90.6%
1987 p=.0262' 93.0% 75.0%

# Expected frequency <5 for at least one cell.

In 1987, metropolitan renal physicians were
significantly more likely than outstate renal physicians
to believe that more home hemodialysis should be used in
treatment of end-stage renal disease. Findings were in
the same direction but not significant at the 23.05
level in 1980. Clotting of the access graft is a common
problem among hemodialysis patients that requires
emergency hospitalization. Perhaps less favorability to
more home hemodialysis among outstate physicians results
from a recognition of the difficulties that home
hemodialysis patients may have in getting to hospitals
quickly. Finally, in 1980, Outstate physicians were
'significantly more likely than were Metropolitan area

178

physicians to agree that end-stage-renal-disease
knowledge in the United States is superior to that
abroad, perhaps reflecting less ethnocentrism among the
more cosmopolitan renal physicians.

Source of Income

Prior research indicates that salaried physicians
are generally more liberal than those who work on a fee-
for-service basis. Mechanic (1974) found physicians
paid on a fee-for-service basis more resistant to
innovations in health care delivery than those with
other sources of income. Strickland (1972) found
salaried physicians more favorable than fee-for-service-
physicians to National Health Insurance (1972) and
Colombotos found percentage of physician's income in
salary positively correlated with favorableness to
National Health Insurance (Colombotos, et al., 1975).
Babbie found favorableness to National Health Insurance
negatively related to the number of private patients
seen by physicians who were faculty members (1970).
These differences are usually interpreted as reflecting
physicians' personal economic interests.

In the present study, in 1980 respondents receiving
more than half of their incomes in salary were
significantly more likely than others to answer that
renal patients should have more influence in selecting

their therapy, an indication of micropolitical

179

liberalism (see Table 7.9). In 1987, differences were
in the same direction but not significant at the p=.05
level. By 1987, while they were still more conservative
than the more-salary-dependent, the less salary-
dependent had increased their approval of micropolitical
democracy between 1980 and 1987, perhaps in response to
malpractice insurers' pressures for patients to have the
opportunity for "informed consent."

In 1987, renal physicians receiving less than half
of their incomes as salary were significantly more
likely to favor a "free market" in renal care
(suspending certificate of need requirements) than were
more-salary-dependent renal physicians. Working in an
unsalaried position involves renal physicians in direct
concerns with generating revenues, and this may explain
their greater favorability to suspending certificate of
need.

In 1987, more-salary-dependent renal physicians
differed from the less-salary-dependent in agreeing that
transplant facilities should be regionalized. This
probably reflects the less-salaried physicians'
preference for a free-market, rather than a planned,
approach to transplantation. In 1980, differences
between more-salaried and less-salaried renal physicians
on the issue of regionalization were in the same

direction but not significant at the p=.05 level.

180

Table 7.9. Significant relationships between
source of income and dependent variables.

Over half
from
salary
(1980 n=43)
(1987 n=48)

Qualified physicians
should be free to
establish practice

without CON.

1980 93.7843 54.1%
1987 93.0065 35.0%

Should regionalize
transplant facilities.

1980 93.1722 63.4%
1987 93.0284 79.2%

Patient should have

more influence in

therapy selection.

1980 93.0307 52.4%
1987 93.3071 53.8%

Capitation affects
selection of

treatment modality.

1980 NA
1987 93.0220 72.7%

181

Half or
less from
salary
(1980 n=20)
(1987 n=32)

57.9%
69.2%

45.0%
56.3%

22.2%
32.3%

NA
46.9

In 1987 salaried renal physicians were more likely
to agree that composite capitation payments (expected to
influence physicians to recommend the less expensive
treatment modalities) do affect the selection of
treatment modalities than were those less dependent on
salary income: that is, they were more likely to agree
that a centralized federal cost control mechanism was
effective.

In general, more-salary-dependent renal physicians
differed from the less-salary-dependent in making more
liberal responses: 1) in 1987 they were more likely to
agree that a government regulatory mechanism, the
composite capitation payment was effective: 2) in 1987
they were more likely to accept the regulation implied
in regionalization of transplant facilities: 3) in 1987
they were less likely to favor abandoning the
centralized planning involved in certificate of need
requirements: and 4) they were more likely, in 1980, to
favor greater interpersonal democracy in medical
decision-making.

Profit-Making and Not-for-Profit Settings

Renal physicians practicing in a profit-making
setting would logically be more likely to accept the
notion that medical care should be organized on the same
principles as an efficient business, and this should

affect their attitudes about both policy and patients.

182

However, this variable was not highly associated with
renal physicians' attitudes. Part of the problem was in
the small number of renal physicians responding to the
survey who practiced in profit-making settings: in 1980
it was fourteen, and in 1987 it was twelve. In 1980
renal physicians receiving half or more of their incomes
in for-profit facilities were less likely to agree that
they had been influential in establishing renal policy
in the region than were those receiving less than half
of their incomes in profit-making settings (see Table
7.10). Regional policy had limited the growth of for-
profit renal care in the state, and perhaps for-profit
practitioners were unwilling to concede this.
Table 7.10. Relationship between percentage
of practice time physician spends in profit-
making setting and dependent variable.
More than Half or
half less
(1980 n39) (1980 n=54)
(1987 n=12) (1987 n=64)
Renal physicians
are influential in
setting policy.
1980 93.0385# 0.0% 40.0%

# Expected frequency <5 for at least one cell.

Type of Practice

Both Strickland (1972) and Colombotos et al.,
(1975) found hospital-based practitioners more liberal
about National Health Insurance than were office-based
physicians. Colombotos believed this occurred because

183

the former "have already committed themselves to many
conditions of work which office-based practitioners seem

to fear" (1975:391).

Table 7.11. Significant relationship between
medical setting of practice and dependent

variables.
Office Hospital
setting setting
(1980 n=21) (1980 n=33)
(1987 n=19) (1987 n=35)

Favor government

regulation of

ESRD program.

1980 93.0033 25.0% 66.7%

1987 93.8310 62.5% 65.6%

In the present study, hospital—based physicians
were more liberal than the office-based in 1980 in one
respect: hospital-based renal physicians were much more
likely to agree that it was important for the government
to regulate the end-stage-renal-disease program (see
Table 7.11). By 1987, approval of government regulation
of the end-stage renal disease program was about 60%
among both office-based and hospital-based physicians.
Perhaps by 1987, office-based physicians, like hospital-
based physicians, had committed themselves to the
"conditions of work" involved in government regulation
of the ESRD program.

Organization of Medical Practice
Several studies indicate that the organization of

184

physicians' practices is related to their attitudes.
Goldman and Ebbert found medical school faculty most
politically liberal (1973) and Goldman found medical
school faculty most medically liberal (1974b), followed
by multispecialists, single-specialty group members, and
solo practitioners. Mechanic (1974) found physicians
practicing in groups more receptive to innovation in
health care delivery than were solo practitioners.
Eliot Freidson reasons that solo practitioners tend to
behave like small-scale entrepreneurs and to develop
attitudes appropriate to small businessmen, financially
dependent on their clientele, and striving to please
them. Physicians in academic medical centers, protected
from many financial concerns, tend to take the role of
the physician craftsman. Their artisan approach to
medicine and their presence in an academic setting is
believed to predispose medical faculty to relatively
liberal attitudes on medical practice and politics.
Physicians in group practice are believed to focus on
rules in their roles as physician-bureaucrats (Freidson,
1975). Physicians practicing in a multispecialty
setting are supposed to be liberalized by their exposure
to the opinions of specialists in other areas of
medicine.

In the present surveys, organization of practice is

significantly related to only one issue, whether renal

185

transplantation should be regionalized. It is
significant in both 1980 and 1987 (see Table 7.12), with
medical faculty more in favor of regionalization than
renal physicians who practice in other settings. Small
numbers of both solo practitioners and those practicing
in multispecialty settings may have rendered this
variable less useful than it would be with a larger
sample of physicians.

Table 7.12. Relationship between organization

of practice and dependent variables.

Agree that transplant facilities should be

regionalized.

1980 1987
Practice
Organization 93.0017# 93.0136#

Full-time Faculty 82.6% (n=23) 92.0% (n=25)
Multi-Specialty 36.4% (n=13) 41.7% (n=12)
Single-Specialty 30.0% (n=21) 67.6% (n=34)
Solo Practice 72.7% (n-ll) 70.0% (n=10)

# Expected frequency <5 for at least one cell.

Changing the Setting of Medical Practice

In 1987, over 20% of renal physicians who had been
practicing end-stage renal care in the region in 1980
were no longer practicing that specialty in the region.
In addition, by 1987 more than one fifth of renal
physicians in the state had changed the locations of
their practices within the region in the past five
years. According to interviews and written comments by
renal physicians, both out-of—region and within-region

186

migration and leaving the specialty may reflect stresses
associated with caring for patients with chronic
diseases, disillusionment with the end-stage-renal-
disease program, displeasure with regional renal policy,
resources and politics, or dissatisfaction with certain
elements of the specific practice setting.

Renal physicians who had changed the settings of
their practices in the last five years were
significantly less likely to agree that the ESRD program
would be a good model for other catastrophic disease
programs than were non-changers (see Table 7.13).
Setting-changers were significantly less likely to agree
that large corporations involved in ESRD service
delivery have a positive impact on patient care than
were non-changers. Finally, setting-changers were
significantly more likely than other renal physicians in
the region to believe patients should be more
influential in selecting their own treatment modalities.

,In sum, setting-changers seem to have rather
populist notions, having negative views of the role of
government and large corporations in ESRD care, but

favoring greater power for patients.

187

Table 7.13. Significant relationships between
physician's changing practice setting between
1982 and 1987 and dependent variables.

Physicians Physicians
changing not changing
setting of setting of
practices practices

(1937 n317) (1987 n365)

Government model
is good for other

catastrophic

diseases.

1980 NA NA
1987 93.0244 25.0% 56.7%

Patient should

have more

influence in

therapy selection.

1980 NA NA
1987 93.0116 64.7% 31.3%

Large corporations

have positive impact

on patient care.

1980 NA NA
1987 93.0097# 00.0% 23.1%

# Expected frequency <5 for at least one cell.

188

Structures-of-Practice as Independent Variables

In this study structure-of-practice variables
are less powerfully related to renal physicians'
attitudes than was expected. In addition, relationships
that were significant in 1980 were no longer significant
by 1987, and significant relationships appeared in 1987
that had not appeared in 1980. Only one relationship,
that between organization of medical practice and
regionalization of transplant facilities, was found
significant in both 1980 and 1987. Some conditions of
end-stage renal disease care had changed between 1980
and 1987: 1) The Network Councils, instruments of
physician policy making, were threatened with loss of
funding: 2) composite capitation provided incentives for
renal physicians to place patients on the least
expensive therapies; 3) the diagnosis-related-group
concept, applied to patients with kidney failure,
complicated their receiving ongoing renal care while
hospitalized for other ailments; 4) improvements in
peritoneal dialysis made it possible for a greater
percentage of patients with renal failure to dialyze
at home.

If structure-of-practice variables are less
powerful than expected, perhaps it is because the
unstable external environment affected renal physicians'

attitudes in concrete and usually understandable ways.

189

In addition, relatively high levels of meeting
attendance and professional group membership may have
been the basis of shifting coalitions. Participation in
the transplantation group, the Kidney Foundation's
advisory board and the Network Council gave many
physicians forums to debate issues in the renal disease
program. Coalitions formed on various issues may have
provided untraditional axes along which renal physicians
could polarize, negating the strength of practice
setting (office or hospital) and structure-of-practice
(solo, single-specialty, multi-specialty, or faculty)
variables. Attitudes resulting from coalition formation
cannot be well predicted by social structural variables.
In other words, differences between groups of physicians
may reflect the results of what Lauer and Handel have
called "a situated struggle rather than a value"
(1983:189).
Political Climate and Renal Physicians' Attitudes

The national political climate and the climate in
renal care both provide an ethos which can be expected
to influence physicians' attitudes. Glasser, et al.,
(1980) found that between 1972 and 1977, physicians'
reactions to constraints on their autonomy became
increasingly negative. In the Reagan era of increased
emphasis on free enterprise, greater conservatism on

health policy issues might be expected among

190

respondents.

Questions about renal physicians' agreement with
policy that would move ESRD care in the United States
closer to models of nationalized health care established
elsewhere were asked in both 1980 and 1987 (see Table
7.14). In seven years, answers generally reflected a
change toward more acceptance of the kinds of principles
on which national health care is often based. Although
none of these changes is significant at the 93.05 or
better level, the direction of change does not reflect
the increased conservatism evidenced in recent national
elections in the United States.

The greatest degree of change toward the tenets of
nationalized health care was in the percentage of renal
physicians favoring government involvement in end-stage
renal disease, followed respectively by the change in
favorability to regionalization of kidney transplant
facilities, consumer involvement in policy-setting, and
government regulation of the disease program.

There was only a slight increase in respondents'
favorability to a free market in renal care and in
approval of general limits on (or rationing of) end-
stage renal disease care and age limits for end-stage-
renal-disease care. There were decreases in percentages
of renal physicians favoring limiting care based on

other chronic diseases (see Table 7.14).

191

Table 7.14.

Changes toward "liberal" stance

in renal physician attitudes on issues related
to nationalization of control of the ESRD

program.

Favor government
involvement in the
ESRD program.

Favor regionalization
of transplant
facilities.

Favor increased
consumer involvement
in ESRD policy-making.

Favor government
regulation of
the ESRD program.

Favor limits on ESRD
care.

Favor certificate-
of-need requirements
to enter ESRD care.

Favor limits to ESRD
care based on age.

Favor limits to ESRD
care based on
comorbidities.

1980

(n=68)

27.3%

56.9%

56.5%

51.5%

74.6%

51.7%

43.9%

65.2%

192

1987

(n=85)

40.8%

69.9%

67.1%

60.8%

74.4%

50.7%

41.2%

58.8%

Percent
change

+13.5%

+13.0%

+10.6%

+9.3%

+0.6%

-l.0%

-2.7%

-6.4%

These changes might indicate that renal physicians
in the region have become more receptive toward federal
and consumer involvement in ESRD care. At the same
time, however, there has been some movement away from
approval of restriction of benefits or the rationing of
renal disease care. In summary, in Freidson's
terminology, renal physicians seem to have moved to
acceptance of greater government intervention in "terms
of work": that is, government involvement in and
regulation of renal care and whatever central planning
and consensus might be involved in the regionalization
of transplant and consumer involvement in policy-making.
At the same time, they are slightly less favorable to
intervention in the "content of work" involved in
deciding which patients should receive care (l970b:55).

Riska (1985) has argued that the ESRD Network
Councils essentially maintained the status quo. Renal
physicians' increasing favorability toward the ESRD
program might reflect their satisfaction that while it
has, in some respects, limited their autonomy, it has
also strengthened their control of the specialty,
heightened their prestige, and increased their incomes.

Thus, there are two possible interpretations of
longitudinal changes in the state's renal physicians'
attitudes. One, suggested by the interpretations of

Goldman and Colombotos, is that the state's renal

193

physicians' are relatively receptive to the tenets of
national health care. The second, suggested by Riska
(1985), is that the major effect of the ESRD program is
to give consumers buying power in the medical market
place that constitutes health care in the United States.
Many national trends in renal care would tend to support
Riska's argument: Some states have dispensed with
certificate-of—need requirements for entry into renal
care, although that is not the case in the state
surveyed. Recent changes in tax laws have made it
advantageous for renal physicians to establish
physician-owned private corporations. Peritoneal
dialysis technology permits renal physicians to enter
renal care without expensive investments in hemodialysis
facilities. Introduction of composite capitation
payments in renal care will enable most facilities to
preserve their incomes. In essence, the ESRD program is
moving closer to the market model of medical care. If
renal physicians' approval of the ESRD program is
increasing, some of this approval is probably rooted in
the program's closer conformance to a market model.
However, some portion of this approval is also likely to
be rooted in physicians' realization that, in the
current economy, federal involvement and regulations may
be the only feasible way to finance end-stage renal

disease care.

194

Chapter 8
Conclusions-

In the United States, concern over escalating
health care costs, coupled with concern over the large
part of the population that is medically uninsured or
underinsured, has stimulated renewed interest in reforms
to decrease the fraction of the gross domestic product
devoted to medical care and to increase the percentage
of the population with adequate health insurance.

Most of the recently proposed reforms would occur
within the current private systems of health insurance
and health care delivery, with minimal public
regulation. However, a significant interest group,
worried that business will have to absorb costs of
increased health insurance coverage, is considering
public health care as a way to reduce business costs:
executives in large corporations, concerned about the
sizable increment that employees' medical benefits add
to the cost of their products, are studying Canada's
public health system as a possible model for the United
States (9e;zei§_£ree_29eee, 1989).

While examining other nations' successful health
care programs for possible application in the United
States is a long overdue project, it is equally
instructive to study the few efforts in the United

States that constitute partial national health care

195

programs. The two most comprehensive such programs are
federally-funded nursing home care and federally-funded
care for people with kidney failure. Bruce Vladeck
(1980) has studied the inability of federally-funded
nursing home care to provide adequate, fairly-priced
care. He attributes these problems primarily to the
government's failure to effectively regulate the
private, profit-driven system that delivers most nursing
home care. In the United States, the end-stage renal
disease program has presented an opportunity to study a
natural experiment in the catastrophic-disease approach
to national health insurance.

My study has examined the end-stage renal disease
program in an effort to draw conclusions relevant to the
implementation of other catastrophic disease programs
from it. Until we understand the social conditions and
physicians' attitudes and behaviors associated with both
the positive features and the flaws of the end-stage
renal disease program, we cannot implement other federal
catastrophic disease programs intelligently or expect
physicians to cooperate with such programs. For many
reasons, attitudes do not always translate directly into
behavior; however, they are important in that they are a
"predisposition to act in some way" (Lauer and Handel,
1983:93). The present organization of health care

endows physicians with enough formal and cultural

196

authority to determine the success of any alternative
system of health care. Therefore, it is important to
understand the attitudes of a group of physicians
already in an alternate system--the ESRD program--and
the issues that arose in the program. In addition, the
social and historic background of the program have
provided an important context for interpreting
physicians' attitudes about these issues.

In the case of medical care, physicians' ability to
invoke their professional autonomy as a shelter against
regulation compounds the government's traditional
reluctance to regulate programs involving public funding
of private industry. Freidson has argued that
physicians' protection of their professional autonomy is
broader than necessary, for it includes seeking to
control "terms of work" (e.g., wages, hours and working
conditions), not necessary to professional autonomy, as
well as to control "content of work" (diagnosis,
prescription, and collegial evaluation of medical work),
necessary to professional autonomy. He attributes many
inadequacies in health care in the United States to this
overly broad interpretation of professional autonomy. I
began looking at renal physicians' attitudes about
various autonomy-related issues to try to understand the
possible relationship of physicians' autonomy to

problems in the development of policy in the public

197

(federal) end-stage renal disease program.

Many issues in the ESRD program seem to have been
directly or indirectly related to the question of renal
physicians' autonomy within a federal program. A
general question was renal physicians' attitudes about
which people or groups should make policy. More
specific questions assessed physicians' attitudes about
ways to increase the program's low cost-benefit ratio,
(e.g. rationing ESRD care, setting quotas to encourage
adoption of the less expensive treatment modalities, and
limiting the number of transplant facilities).

Because of regional idiosyncracies in the ESRD
program, the conclusions of my study cannot be
generalized to all renal physicians in the United States.
However, they probably are indicative of the sorts of
issues that have become critical elsewhere. Examination
of these issues in other regions could provide
fascinating material for comparative sociological
analysis. Further, any other federal catastrophic
disease program must confront similar issues. To the
extent that problems in the ESRD program were tied to
the social structure of the program, preventing them
will be easier and less expensive than attempting to
solve them after vested interest groups have already

polarized around them.

198

Democracy: Who Is/Should Be In Charge?

Policy in any public health care program inevitably
involves two levels, the micropolitical (diagnosing and
prescribing a treatment regimen for the individual
patient) and the macropolitical (general principles that
guide the treatment of all patients). Policy making by
vested interest groups has characterized the United
States' end-stage renal disease program. On the
micropolitical level, those with vested interests
include the patient or a representative of the patient
and the physician; at the macropolitical level, those
with vested interests in the United States include
physicians, patients, taxpayers, government bureaucrats,
and private corporations. Although these groups might
conceivably have worked to create policy that limited
renal physicians' professional (content of work)
autonomy, they are more likely to have taken initiatives
that limited physicians' extra-professional (terms of
work) autonomy. Freidson (l970a:55) has argued that
physicians, to preserve their professional autonomy,
engage in anti-democratic activity: "...[they] seek to
build barriers that keep the profession and its
clientele safe from those beyond the pale while at the
same time seeking jurisdiction over all that cannot be

excluded."

199

Physicians

Following the reasoning of Freidson, we would
expect physicians to resist attempts by other groups to
influence the renal disease program. According to the
experience in this state, has renal physician resistance
to input from other groups been so high that meaningful
public regulation of state-funded medical programs is
unlikely? Nearly all respondents would have preferred
more medical professional involvement in planning and
administering the renal disease program, a finding that
tends to support Freidson's notion that physicians seek
to keep their professional activities safe from those
"beyond the pale." However, while only about one-
fourth viewed the Network Council as very influential in
policy making, only one fifth thought the Council should
have more power. This finding does not support a view
of these renal physicians as a group constantly seeking
to expand and consolidate their own political power.
Consumers

In addition, the majority of survey respondents
agreed that consumers should have more influence on
renal policy. An even greater level of acceptance of
consumer input between 1980 and 1987 seems to indicate
an increasing openness to broader-based, more democratic

decision-making in renal policy.

200

Government

The majority of respondents viewed government as
curtailing physicians' professional autonomy, but they
agreed on the importance of federal regulation of the
ESRD program. How can this diversity of seemingly
conflicting results--that physicians would prefer
medical professional planning and administration of the
program but accept government regulation; that most do
not want more renal-physician policy-making power but
would welcome more consumer input into policy--be
reconciled? First, physicians seem ambiguous about the
role of the government in renal care. In the words of
one renal physician interviewed for this study:

"I think, as usual, the government
tends to be a double-edged sword.
Some good, some bad—-it would be
hard to say in the balance."

Other renal physicians' elaborations in written
remarks and interviews suggest that they are more anti-
bureaucratic than anti-democratic: When the state's
renal physicians criticized government, their critique
is directed at bungling bureaucracies. Medical
professional planning and administration of the program,
which they favored, would be one way to avoid such
ineptitude. None of the physicians mentioned a problem
with "socialized," medicine; few mentioned concerns

about the political economy of health care. Their

201

favorableness to government regulation of renal care
appears to reflect a realistic assessment that of public
rights to oversee a public program.

In general, these results support the analyses of
Goldman and Colombotos in casting doubt on the
traditional stereotype of United States physicians as
political conservatives whose political conservatism is
mirrored in their attitudes about health care.
Large-Scale Corporations

The federal government's high payments to near-
monopoly renal care corporations in other regions has
spurred their growth and positioned them to control
regional renal care markets and to curb physician
autonomy in such regions. As has been noted, the
state's renal physicians had successfully limited the
expansion of large-scale proprietary renal care in the
state, and they viewed it as less threatening to their
autonomy than was the government. The latter response
indicates little appreciation of the demonstrated
success of large renal care corporations in lobbying for
legislation favorable to themselves, regardless of the
impact it might have on renal physicians practicing in
smaller settings in other regions (Kolata, 1980b:
Plough, 1986). This result supports Paul Starr's notion
(1982) that physicians, in focusing on government

threats to their autonomy are somewhat naive about more

202

serious threats to their autonomy that monopoly capital
domination of medical care could entail.
Patients

Since only about 40% of the renal physicians being
surveyed were willing to give patients more influence in
selecting their own treatment modalities, but most were
willing to give consumers more voice in policy—making,
they apparently are more receptive to democratization on
matters related to terms of work than about matters
related to content of work. In fact, the issue of
content of work, whether or not physicians could have
articulated it as an issue, seems central to several
of their other responses: Composite capitation payments,
which provided incentives to change the treatment
regimen they prescribed--content of work issues--were
regarded as a way of altering, but not optimizing, the mix
of treatment modalities used in the state and as eroding
high-quality care. In addition, respondents were highly
negative about the impact of corporations on the quality
of patient care, another indication of the importance of
the content of medical work as a volatile issue.
Limitations of Policy Making by Vested Interest Groups

The problem of who should control the ESRD program
was more obscured than resolved by giving a number of
interest groups partial control over the ESRD program.

At the macropolitical level, professional autonomy was

203

transformed into policy making by vested interest
groups. This approach resulted in difficulty in holding
either individuals or groups accountable for problems in
the ESRD program (Riska, 1985). For example, renal
physician respondents in the state were relatively
positive about measures that could reduce costs of the
renal disease program, including certificate-of-need
regulations (intended to prevent expensive duplication
of services), regionalization of transplant facilities,
changing the mix of treatment modalities, and excluding
some patients from ESRD care. Most respondents
indicated in both 1980 and 1987 that the present
treatment modality mix in the state was not optimal and
would have preferred more use of the less expensive
modalities. Although almost all of physicians desired
this sort of change in treatment modality mix, they
apparently did not view the sum of their individual
efforts as having brought about this ideal by 1987. My
interpretation is that although these respondents, as

. physicians, are quintessential professionals, endowed
with expertise, structural power and cultural authority,
they felt powerless in the face of various social
constraints to bring about their ideals in renal care.
These constraints were not inconsiderable: early on
there were financial disincentives to home care for both

patient and physician, later there was difficulty in

204

trying to convince patients accustomed to in-center
treatment that the freedoms gained by taking on home
treatment would more than offset the burdens incurred,
and there was the lingering suspicion that some
colleagues would continue prescribing on the basis of
profit considerations rather than on patient and social
welfare criteria. That individuals, even powerful ones,
should feel overwhelmed by social and cultural forces is
not a revolutionary sociological conclusion.

However, people who feel powerless as individuals
often realize the effectiveness of collective action.
Presumably, the Network Council could have initiated
collective action to resolve cost-control issues.
However, the representatives of renal physicians (one
per facility) sitting on the Network Coordinating
Council did not act to change the therapy mix in the
state, to establish rationing principles, or to limit
the number of transplantation centers, nor did they
appear to view such action--one that would permit the
charge they were interfering with the content of medical
work--as within their scope. Thus, the interest-group
liberalism that had functioned to create one of the
finest state-level programs for the treatment of kidney
failure prior to the federal government's program, was
relatively ineffective when confronted with the

necessity of acting in a national context. Under the

205

original mandates of the end-stage renal disease
program, renal physicians in the United States enjoyed
much greater autonomy than do their counterparts working
in other nations' public health systems. However, only
about one-quarter of the respondents to this survey
viewed renal physicians as being very influential in
policy making through the Network Council. This
paradoxical perception, one of having little control in
a situation that originally granted renal physicians
great autonomy, is probably rooted in American
experiences of democracy as well as in several aspects
of renal physicians' work.

As a heavily bureaucratized nation, we have come to
accept the inequality inherent in hierarchy as the
tradeoff for efficiency. As a nation of non-voters, we
have come to accept the principle of minority rule by
vested interest groups. As a result, we experience
democracy as rhetoric more often than we experience
democracy as action. Having little experience of
democracy, we have difficulty making it work and become
impatient with its inefficiency. This may be especially
true when occasions for democratic participation are
offered in the tortuous guise of interest-group
liberalism. Thus, the respondents to this survey seem
to have felt powerless to act on many problems that

arose in the renal disease program. In addition to a

206

cultural context that devalues equality and democracy,
the conditions of renal physicians' work may increase
their sense of the limits on individual effort and the
difficulties of planning ahead. The work-related
factors that appear to have affected renal physicians'
attitudes include burnout and physicians' action
orientation.
Burnout

The daily realities of end-stage renal disease care
may have important influences on renal physicians'
attitudes. These realities include treating a disease
that is "endestage" (perhaps an example of "avoidance
rhetoric"), or terminal. Even though recent
technologies have commuted the end-stage renal disease
death sentence, both practitioner and patient must be
vigilant, for iatrogeneses and potentially fatal mishaps
are ever-present possibilities in both dialysis and
transplantation (Olmsted, 1989). For example, Belding
Scribner's first hemodialysis patient developed six
consecutive diseases related to the dialysis, each of
which required invention of an appropriate therapy; and
deterioration of cannula sites required re-cannulation
from forty to-fifty times in ten years for a single
patient (Heinz, 1971:29).

For the physician, the metaphor of a mechanic

attending a machine may be a psychological defense

207

against the costs of delivering chronic, crisis-ridden
care. In addition, I have shown that the popular press,
employing humanizing and often religious metaphors for
scientific techniques and technologies used in treating
kidney failure, reduced the people receiving treatment
to machines in need of repair. A number of critics have
pointed out that this reductionistic glorification of
science in medicine diverts attention from social
factors in health, depoliticizing health care issues
(e.g., Riska, 1985). Although most analysts point out
the dangers of a depoliticized general population,
physicians are not immune to depoliticization.

This scientistic approach also may entail
psychological difficulties for both patients and
practitioners, as becomes evident in the observations of
one nephrologist:

"... when you take care of people who have
serious chronic illnesses on a long-term
basis, you've got to make sure that you have a
system designed so that you have enough
supports to do that, to provide for that care.
We have not yet worked out the systems well in
nephrology from my perspective...We pay for
having patients come in the hospital and
getting their grafts declotted and having
surgical procedures and things like that, but
just daily ongoing care--we're miserable at
it. I don't care whether it's hearts or
livers or pancreases or whatever."
This physician is reacting to the results of a
reductionistic system of health care, one that is

technologically sound, restoring the patient to

208

satisfactory mechanical functioning. However, there is
a deficit in "daily ongoing care" that is outside the

realm of scientific medicine, which is ill-equipped to
cope with the enormous consequences of the life-saving

techniques and technologies it has developed:

"Those people will shift from people who would
have died to people who will have lived and
are now living with chronic diseases. And we
don't have systems in place here yet to take
care of chronic diseases well. And until we
understand the ramifications of that I think
we should be very leery in terms of funding
other catastrophic illnesses. These patients
are so fragile. They are so disabled. They
are so psychologically problematic, not
because their personalities necessarily are
bad but because they're having to deal with
such a huge problem that people will come into
it because they think 'Oh, my gosh, its such a
great thing,' and have that feeling as though
they can conquer the world. And what happens
is that after they're in it for two or three
years, they find it's such a drag that they
have to get out."

Medical staff may "get out" by leaving renal care;
patients, by an overt decision to die (by stopping
dialysis treatment) or by a more subtle decision to die
by not complying with the requirements of the treatment
regimen:

"I see a tremendous amount of noncompliance.

The patients--older patients on dialysis--I'm
just sure its depression. And there's
absolutely no way that I can get these people
treated effectively just because there's no
way to have that sort of thing covered...."
The "sort of thing" the physician refers to

includes psychological and social services to patients

209

with renal failure. He attributed loss of these
services to cost-control measures:

"We don't have the social services or the

psychological services for end-stage renal

disease patients now that we had ten years

ago. They're drastically reduced. And I

think that's one of the major problems ....

We don't have ways to get them rehabilitated.

We don't have ways to have them work...

through their depression and find ways of

coping and adapting."

Both patient and practitioner may find it difficult
to come by the psychological resources necessary to
continuing the battle against end-stage renal disease
(Olmsted, 1989). The lack of extra-clinical support for
patients with chronic disease had reduced the meaning of
this physician's work to keeping some people alive but
unhappy. This circumstance effectively ends the
notion that scientistic, reductionistic medical care is
a worthwhile endeavor and results in an anguished
questioning of meaning:

"...what we're doing is we're keeping people

alive who are depressed and unhappy with life.

That spills over on dialysis staff. They

don't know how to do it. They come here and

they're noncompliant. And it's a situation

where everybody is just kind of saying, 'Oh,

my God, what am I in this for?'"

Ultimately, emphasis on technological solutions to
health problems is not only intellectually unsound, but
also emotionally impoverishing. The view of the human
being as a number of mechanical systems that function

more or less imperfectly is alienating to both patient

210

and practitioner, and this is made obvious when the
health condition is chronic and punctuated by crisis.
Action Orientation

Another physician remarked that he dealt with his
patients' chronic, and often progressively deteriorating
conditions by compartmentalizing, trying never to take
patients' problems home with him. Treating patients
with chronic problems may, in and of itself, tend to
reinforce physicians' orientations to activism,
pragmatism, and clinical knowledge. Renal physicians'
tendency to identify problems with the renal disease
program in the mechanisms of government bureaucracy
rather than in the underlying political and economic
structure may well be grounded in the worldview and
orientations that characterize clinical practice. Such
a present-oriented and narrow focus, necessitated by the
physicians' need to treat the patients' unique symptoms
as they arise as well as by physicians' desire for
psychological certainty, could also have the effect of
diverting the physician from concern with political
issues in the renal disease program.

Policy‘Implications

In the absence of a comprehensive national public
health care program, the success of any program similar
to the end-stage-renal-disease program will depend on

policy planned and implemented to avoid the problems

211

encountered in the end-stage-renal disease program.
Such policy would undoubtedly place more restrictions on
physicians' extra-professional autonomy than did the
end-stage-renal-disease program. Although the United
States' failure to have more publicly funded health care
is often attributed to the power and resistance of
physicians, the results of this study suggest that-new
programs modeled on the renal disease program would not
face incapacitating opposition from physicians.
Oligopoly Medicine

The results of this study also indicate that
physicians underrate the impact that near-monopoly
medical care could have on their practices. In
addition, the effect of large medical corporations on
the quality of patient care has, as yet, to be proved
positive. For any future government health care
programs, if large-scale proprietary medical care is not
excluded from participation, the consequences of dipping
into public coffers to enrich and strengthen the
monopoly sector should be carefully evaluated. If
physicians behave increasingly like businessmen, it is
likely the government will increasingly apply anti-trust
rules to a group formerly allowed by the rhetoric of
professional ethics to set "usual and customary" rates.
Although the government can always use anti-trust

actions to break the power of these medical near-

212

monopolies, it might be that the long-term costs
resulting from strengthening monopoly medicine would
outweigh the short-term benefits of any programs similar
to the ESRD program.
Planning

Most critics of the federal end-stage renal disease
program say that cost overruns were the major problem
with the program. An important reason for early cost
overruns was too much use of the then-most-profitable
treatment modality, in-center self-dialysis by patients
well enough to dialyze at home. Part of the reason for
the decrease in home dialysis was the sudden increase in
patients eligible for care following passage of the
federal legislation. A nephrologist describes the
change from a time when diabetics and those over age 55
were excluded from ESRD care at his facility to the 1973
legislation which funded treatment for nearly all people
suffering from kidney failure:

"The inundation which took place in 1973

really overwhelmed our capabilities. We found

that the home dialysis program really just

went down the tubes. The reason for that was

that funding now was readily available. We

were having a very difficult time keeping up

with the recruitment and training of our own

staff, let alone the training of the

patients....It was difficult to make

projections because there really was no ready

formula by which you could plug in, in that

year of 1973."

This physician could not make projections about the

potential increase in patient load at his facility

213

because there were no adequate statistics on which such
a projection could be based. The implications for any
other catastrophic disease program are clear. Because
of the large proportion of the population that is
medically uninsured or underinsured, projection costs of
new federal health care programs must include this
segment of the population. Basing new programs on sound
statistics would also allow facilities to plan cost-
effective treatment for those newly eligible for care.
Accountability

Until now, I have treated the content of medical
work and the terms of medical work as if they are
mutually exclusive categories. However, as the history
capitation legislation shows, the government has enacted
legislation that provided financial incentives for renal
physicians to provide first the most expensive, then the
cheapest (but not necessarily the optimum) treatment
modality. Any other federal medical program must
establish a system that interferes minimally with the
content of medical work, but at the same time is
impervious to profiteering. It is unlikely that this
delicate balance can be attained in a private system of
health care controlled by vested interest groups. In
the ESRD program, many individual physicians continued
to act altruistically, despite financial incentives to

do otherwise: for example, one cited to me statistics

214

for his patients indicating a treatment modality ratio
superior for cost effectiveness to that achieved by the
low-cost states of Washington and Indiana. However,
despite the existence of many altruistic renal
physicians, when they were constrained to act as members
of interest groups they could not act to achieve the
public interest. This finding suggests that an
alternative to policy making by vested interest groups
is essential to the success and public accountability of
any future catastrophic disease programs.
Wholism

Another inadequacy of the ESRD program was its
failure to acknowledge patients and practitioners as
beings who need psychological and social--not just
mechanical, surgical and pharmaceutical-- services. The
major effect of similar programs could well be to keep
unhappy people alive and to drive many practitioners
into other fields. In avoiding thinking about rationing
care, in avoiding thinking about the implications of
treating an "end-stage" disease, in avoiding admitting
that human beings may need more than mechanical
treatment, the ESRD program has avoided confronting
issues that must ultimately be confronted in
implementing any further federal systems of medical

care .

215

Social Structure of Medical Care

Various social structures (e.g., the medical
school, the medical practice setting, the larger
society) are believed to be important to physicians'
attitudes about issues in health care: first, they
provide socialization into the general culture and into
the various subcultures of medicine: and second, they
provide physicians with vested interests that may be in
conflict with the interests of patients, other types of
physicians, or the general public. Freidson has argued
that different social characteristics of medical
practice give rise to different expressions of
professional autonomy and has suggested that unobtrusive
attempts to control national health policy by fostering
specific structures of medical practice might substitute
for an explicit national health policy. Renal programs
in states such as Minnesota and Washington, dominated by
physicians with formal connections to university medical
centers, do tend to exhibit focus on content of medical
work (finding the optimum treatment modality) that
Freidson (1975) ascribes to the artisan-physician who
is often connected to an academic medical center.
physicians.

The state's program was initiated primarily by

university-connected physicians (described by Freidson

216

as artisan-craftsmen more interested in medical work
than in profits or enforcing rules). At the time they
entered renal care, most did so as Freidson's typical
academic physicians, primarily interested in the art and
craft of medicine rather than the bottom line. However,
by the time of the surveys most renal physicians in the
state had only informal ties to university medical
centers. The weak federation of academicians and quasi-
academicians that delivered renal care in the state did
not bring about as positive a program as might have been
expected.

The results of this study of renal physicians in
one state also illustrate the limitations of looking'
only to structure-of-practice variables to predict
physicians' attitudes on specific issues. Structure-of-
practice variables were not as strongly related to
physicians' attitudes as was expected. Perhaps this
occurred because the federal government, in establishing
the End-Stage Renal Disease Network Coordinating
‘Council, provided a political forum in which coalition
building often overrode the effects of structure-of-
practice variables in forming renal physicians' policy
attitudes. In addition, the program provided financial
incentives for all renal physicians to behave like
proprietary physicians (in order to provide a large pool

of potential transplant patients and to provide social

217

and psychological services). It is possible that
surveys of other physicians, who have not met regularly
to attempt to build consensus and who have not been
subjected to a skewed incentive structure, might find
structure-of-practice variables to be more powerfully
related to physicians' attitudes. However, the results
of this study do not indicate that implementing new
programs in structures believed to foster altruism can

override economic disincentives to altruistic behavior.

218

APPENDI CES

APPENDIX A

Table A.1. Popular press reports on potential for
technological improvements in dialysis and cost savings
in dialysis.

Use of plastic to build artificial kidney makes it
easier to sterilize and move.

Seienee Megs Leggez, 1952 (May 10):291

Sheet dialyzer substituted for tube dialyzer and can be
five times as effective.
Seisntifis_hmerisan. 1954 (191)=26

Kolff uses tin can and garden hose connection as parts
of cheap, disposable, kidney.

Ssiense_usxe_Letter. 1956 (Aug- 25)=123

Throw-away, tin can dialyzer eliminates time-consuming
sterilization and set-up.

Seisnse_uew§_Lstter 1956 (Aug- 25)=123

Use of central, rather than individual, tanks for
purifying fluid for dialysis. Estimated to cut dialysis
costs from $10,000 to $8,500 a year.

Time. 1964 (Apr. 24):42

Batch ordering of chemicals cuts costs from $28 to $21

per dialysis treatment.

High volume in dialysis machines, combined with leasing
arrangement, could drop costs of dialysis equipment to

$3,500 a year.

gesiness Week, 1965 (Mar. 6):92

Artificial kidney made of die-cut, waterproof cardboard
to be cheaper and 50 times lighter in weight than
current artificial kidneys.

§eie9ce News Leggez, 1966 (Aug .13):99

Kolff machine costs only $150 to $300: uses Maytag
washing machine, without the wringer, inexpensive
cellophane and pre-packaged chemicals. Costs about 16 c
per dialysis 'run'.

Besiness Week, 1967 (Feb.4):72

Automating production of the dialyzer expected to bring

prices down.
Newsweek, 1970 (June 1):87

219

Table A.2. Popular press reports on innovations that
reduce incidence of transplant rejection.

Destruction of recipient's bone marrow by radiation,
reinjection of cadaveric donor's marrow.
Time, 1958 (Apr. 28):77

Cortisone, RNA injections.
Time, 1960 (June)

Thymus irradiation, removal of spleen, treatment by
leukemia drug.

§ciemce News Legtem, 1962 (Dec. 8):362

Actinomycin C, imuran, prednisone.
geiemee Newe Lettem, 1963 (Oct. 5): 217

Free patients from infection; reduce blood pressure
before transplant.
Science News, 1967 (June 17):582

Antilymphocyte serum for rejection.
Newsweek, 1967 (Mar. 13):92

Blood transfusion from donor.

Sciemee pigesg, 1980 (Aug.):80

Cyclosporine, Verapamil to block entry of calcium,
believed to be dangerous to kidney.

Esiense_neus 1983 (Mar )= 150

Transplantation from primates.

Nememeek, 1963 (Dec. 30):55

Table A.3. Survival Data on Dialysis Patients in the
Popular Press

One hundred people kept alive by dialysis.
Time 1964 (Nov.l3)

One seven-year survivor.
Robbins and Robbins, 1967

220

Table A.4. Popular press reports of survival data on
patients who have received a kidney transplant.

Six grafts completed: three temporarily successful.
fieiemce News Letter 1952 (Oct. 4):211

Physician survives five months on cadaveric kidney.

Science Qigest, 1954 (June):43

Identical Herrick twins doing well after one week.
Time 1955 (Jan.3)

Identical Herrick twins doing well after five and one-
half months.

§eiemce News Leggez, 1955 (Nov.12)

Of identical twin transplants, six successes, one
failure Seventeen transplants from unrelated donor all
fail. Time 1958 (Apr. 28):77

Of ten identical twin transplants in five years, seven
recipients are still alive.
Newsweek 1959 (Apr. 27)

Since 1954, eleven successes in identical twins. Non-
identical Riteris twin survives 18 months.
Time 1960 (June 27):52

Recipient of kidney from cadaveric unrelated donor
survives four months.

Sciense_ueu§_Letter 1963 (June 22)=389

Herrick twin recipient died spring after nine-year
survival. By 1963, about 10% of 200 attempted
transplants are successful.

Mann, 1964:26

Twin kidney donor has since had three children;
recipient, two.
Time 1963 (Aug. 23):44

Fifty to sixty percent survival rate for transplant
recipients reported.

Business Neek 1966 (Oct. 15)

About half of kidney transplant recipients live at least
two years. Many live up to five years.

U.§. Nems emd Werig Re9or§ 1967 (Dec. 18)
A 61-90% chance of kidney transplant success is

reported.
Montgomery, 1969

221

Table A.4 (cont'd.)

Surxixel
One- Two- Longest

year year

Domo;

Identical twin 100%

14 years Parent/sibling 78% 75% 11 years
Cadaveric 52% 41%

Ross, 1970

Fifty percent chance of rejection or infection to
recipient; ten per cent chance of death within 30 days
of transplant operation.

Boyd, 1976

Of 38 patients who had 44 transplant operations,
27 are still alive: two thirds have functioning kidneys.

Howard National
l-year survival 75% 70%
1-year survival 60% 50%
with functioning -
kidney
Cadaveric donor 75% 60%

Burgen, 1977:64

222

Table A.5. Popular press reports on innovations meant
to increase access to dialysis care

Expand facilities to handle twelve patients. Believed
adequate for state of Washington.
Newsweek, 1962 (June 11):92

Central tanks to treat dialysis fluid enable treatment
of three patients at once.
Time, 1964 (Apr. 24):42

Manufacture routed to nontraditional firms. Sweden
Freezer Manufacturing Company, "used to slimmer profit
margins" Cost estimates by Sweden Freezer:

Home: $8260 a year.

Clinic: $10,000 a year

Goals: Lease at total cost of $3,500 a year.
Eusimess Week, 1965 (Mar. 6):88, 90, 92

Dr. Willem Kolff at Baxter Travenol. Kolff's aim:
inventions to reduce cost of home dialysis to $1500 a
year.

gmsimess Week, 1967 (Feb. 4):72

Disposable artificial kidney 7. Argonne National
Laboratory (Atomic Energy Commission) estimated cost
$5,000 a year (Dr. Ray Lavender).

Newsweek, 1970 (June l):8

223

APPENDIX B

Surveys of renal physicians, 1980 and 1987.
A. Questions that are identical in 1980 and 1987.

In your opinion, should there be any limitations in
the provision of treatment for patients with end-stage
renal disease?

Response range: Tee, Undecided, and Ne.

If yes [to the above question], what factors should be
considered in limiting the provision of ESRD services?

Age, ngez chromic eiseasee, che: (9ieeee S9eeify).

It is important that the government regmlete the
delivery of ESRD services.

Response range: figmomgly egzee to §tmongly gieegree.

What do you think the ESRD patient's role should be

in selecting his or her own treatment for end-stage
renal disease?

Response range: ghouid heve more imiimemce, Hes emeugh
infiuence, smould heve iess infimemee, ghomig have no
influenee.

Do you favor or oppose having more ESRD patients undergo
kidney transplantation?

Response range: §tmongiy favo; to ggmongiy 099ese.
B. Questions that are similar in 1980 and 1987.

1987 wording: Do you favor or oppose having more
patients trained for home hemodialysis?

Response range: fi;;emgiy_fieye; to figmongiy e99ese.

1987 wording: Do you favor or oppose having more
patients trained for continuous ambulatory peritoneal
dialysis?

Response range: §tmomgly favo; to Strengly 099oee.
1987 wording: Do you favor or oppose having more
patients trained for home hemodialysis?

Response range: §tzongiy fevo; to §tromgly e99oee.
1980 wording: Do you favor or oppose having more
patients trained for home dialysis?

Response range: Strongly favor to Stromgly 0990se.

224

Appendix B (cont'd.)

1987 wording: What is your opinion of giving consumers
more voice in decision-making and/or planning of the
priorities in renal care policy?

Response range: §tromgiy egzee to SErengiy disagree.

1980 wording: Would you favor or oppose giving
consumers more voice in decision-making and/or planning
of the priorities in renal care policy? Response range:

Strongly favor to Strongly o99ose.

1987 wording: If a group of nephrologists or a group of
qualified physicians want to provide ESRD services,
should they be able to do so regardless of utilization
rates?

Response range: Tee, Qmeeeigeg, and N9.

1980 wording: The federal government has issued munimum
utilization rates for the accreditaion of dialysis
centers and renal transplantation centers. If a group
of physicians or a health care facility want to provide
ESRD services, how important do you think it is that
they should be able to do regardless of utilization
rates.

Reaponse range: Yer1_1m29rtant 59me_haf_1m2_rtanf
§l1ghtlx_1m2_rtanf Net_1mn_rtant

1987 wording: Would you favor or oppose allowing renal
transplant operations to be done in emiy a few medical
centers?

Reaponse range: Strenglx_faxer to Strenglx_99295_.

1980 wording: Would you favor or oppose allowing renal
transplant operations to be done emiy in a few research-
oriented medical centers? Response range: figremgiy

fevo; to Stgomgiy o99eee.

1987 wording: Less government involvement in the area of
renal disease would improve delivery of ESRD services.
Response range: Strenglx_agree to Str9n912_91§agree.
1980 wording: Less government involvement in the area

of renal disease would improve service delivery.
Response range: gtzongly agree to Skrongiy gisagree.
Since the government's primary involvement is in end;
stege renal disease, this was specified in 1987.

225

Appendix B (cont'd.)

1987 wording: Who do you think presently has most
influence over the decision about treatment for ESRD
patients?

Response range: The mephmoiogist, The renai tramS9lant
su eo , ID§_E§Li§D§. The 9atient's family, Other.

1980 wording: Who presently has most influence over the
decision about treatment for ESRD patients?

Response range: The nephroiogisg, The renal rans
sumgeon, The 9atien9, The 9atient's family, Othem.

1987 wording: The supply of ESRD services is sufficient
to guarantee that any person in the United States who
develops end-stage renal disease will receive adequate
medical care.

Response range: Strongiy eggee to §9999gly_gieeg;ee.
1980 wording: In your opinion, if a person develops end-
stage renal dissease in the United States, is the supply
of ESRD-services sufficient to guarantee that he or she
will receive adequate medical care?

Response range: Strenglx_agree to Strenglx_disagree.

C. Questions asked in 1987 only.

The Federal governemnt's end-stage renal disease
program would be a good model for other Federal
catastrophic disease programs.

Response range: Stronglx_agree to Stronglx_disagree.

Has government policy had an im9emhem§ effect in
limiting physicians' autonomy in treating ESRD?
Response range: Tee and Ne.

 

The impact of capitation on services to ESRD patients
has been:

ReSponse range: Str9n912_posifixe to Stronglx_negafixe

Does capitation favor the adoption of certain treatment
modalities?

Response range: Tee and Ne.

If yee [to the above question], which modalities are
favored?

Response range: Tmeme9iemh, Qemhinuous embmietozy
9emitomeei gialysis, Continuous cyeling peritoneei
gialysis, Cehter hemodialysis, home hemodialysis.

The impact of large corporations, such as National
Medical Care, Inc., in the provision of services to ESRD
patients has been:

Response range: §tmongiy 9ositive to §§memgiy_mege§iye

226

Appendix B (cont'd.)

In the United States, have large corporations, such

as National Medical Care, Inc., had an im9ortant effect
in limiting physicians' autonomy in treating ESRD?
Response range: Tee and N_.

By the time ESRD patients are referred to specialists,
they have received adequate diagnostic and therapeutic
care ("care in U.S. is high-quality" 3 agree).

Response range: firrongiy agree to §trongly disagree.

D. Questions asked in 1980 only.

The responsibility for 9Temmihg government sponsored
health programs should be with the medical profession.

Response range: Strongly egree to §trong1y gisagree.

What do you think the ne9hroiogists role should be

in influencing the patients' choice of treatment for
end-stage renal disease.

What do you think the renal transplant smrgeom's

role should be in influencing the patient's choice of
treatment for end-stage renal disease.

Response range: §houid hev ve mere influence, Hes enough
111L__n_1ue oe. WW Wool h v
imfiuence.

These questions could have been more meaningfully
interpreted had there been more transplant surgeons in
the population.

In your opinion, what is the level of knowledge and
research in the area of nephrology and renal
transplantation in the United States compared to other
Western industrial societies?

Response range: _Nmeh_higher, fiemewhat higher, Somewhat
lower, A lot Tower.

The responsibility for 9Te99img government

sponsored health programs should be with the medical
profession.

ReSponse range: 5119119113929 to W-

The responsibility for _egmimierreriem of government
sponsored health programs should be with the medical
profession.

Response range: §9remgiy_egree to fitrongiy disagre .

These questions were relevant primarily for the planned
international comparisons.

227

Appendix B (cont'd.)

What is your opinion of the ESRD-Network Coordinating
Council's role in planning renal-care policy?

Response range: Shouid have more 9ower, Has enough

9ower, §hould have less 9ower. Should have no 9ower.
In your opinion, how influential have renal physicians

been in shaping renal-care policy for the state ?
Response range: Very infiuentiei, §omewhat influentiel,

Slightly influentiai, Not at all influential.
Because of the federal attempt to dissolve the ESRD-

Network Coordinating Council and confusion about its
present status, reviewers believed answers to the above
questions would be difficult to interpret.

For all questions in the survey, the pon'r kmew response
used in in 1980 was changed to an mmdeeigeg response in
1987.

Open-ended questions

1980: If you were to analyze renal-care policy, what
would you think you would need to know that has 999 been
covered in this questionnaire?

1987: What would you say is positive about the treatment
Of ESRD?

1987: What would you say is negative about the treatment
Of ESRD?

1987: What would you say has been learned from the
Federal government's ESRD program that would be useful
in implementing any other catastrophic disease program?

E. Independent variable information

1980 and 1987: Country of medical education, year of
graduation from medical school, specialty, setting of
practice (hospital or office), organization of practice
(solo, group, multispecialty, single specialty), years
practicing renal care, age, number of professional
meetings attended yearly, percent of care done in types
of hospitals (for-profit, non-profit, state/local
government, federal government), percent of income in
salary, community size.

1987: Names of professional organization memberships,
whether practice setting changes in last five years.

1980: Political views, number of memberships in
professional organizations, osteopath or medical doctor,
sex, personal pre-tax income, number of hospital
affiliations.

228

APPENDIX C

Table C.1.

Overall agreement

Location
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical Education
Educated in U.S.
Educated Abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full—time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or fewer

229

198g
27.3%

3.1087
37.5%
18.5%

9:.5594
33.3%
26.5%

93.8986
29.5%
31.3%

93.3637#
34.9%
20.0%

3.7397#
28.6%
40.0%
31.6%
18.2%

3.2959
22.2%
36.7%

93.6613#
22.2%
30.6%

93.2584
34.2%
20.0%

93.9852
29.4%
29.6%

9=.9075

28.6%
30.0%

Favor government involvement in ESRD care.

1231
40.8%

3.0968
32.5%
51.4%

9=.2049
27.8%
44.6%

93.9681
40.9%
41.4%

93.8749#
41.7%
44.4%

93.7678#
37.5%
55.6%
41.9%
33.3%

93.9895
35.3%
35.5%

93.6780#
36.4%
43.1%

93.9393
40.5%
41.4%

93.8992
40.0%
41.8%

93.7983
42.9%
39.6%

(Table C.1 cont'd.)

Change practice setting
Yes, in last five years
No, in last five years

Physician's age
45 or older
Less than 45

Political views
Conservative
Moderate
Liberal

*3Significance level of 9=<.05.
#3Expected frequency <5 for at least one cell.

230

NA

93.6717
33.3%
27.9%

93.0148*#
6.7%

31.0%

58.3%

93.1386
25.0%
45.6%

93.6063
35.5%
41.5%

NA

Table C.2.

Overall agreement

Location
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical Education
Educated in U.S.
Educated Abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
_Ha1f or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or fewer

Change practice setting
Yes, in last five years
No, in last five years

231

19.59.
51.5%

93.6112
48.5%
54.8%

93.7873
53.3%
50.0%

93.9341
51.1%
50.0%

93.0189*
60.0%
23.1%

93.2588
65.2%
58.3%
40.0%
36.4%

9=.0033*
25.0%
66.7%

93.5358#
44.4%
55.6%

93.2067
57.1%
40.0%

93.5987
48.6%
55.2%

9=.1771
62.5%
45.2%

NA

Favor government regulation of ESRD program.

lflél
60.8%

93.8011
62.8%
60.0%

93.7461
57.9%
62.1%

93.9396
60.9%
60.0%

93.1589#
56.5%
80.0%

9=.1424#
60.0%
90.9%
51.6%
66.7%

93.8310
62.5%
65.6%

93.2196
45.5%
65.0%

93.3385
59.1%
70.0%

93.6156
56.3%
63.2%

93.3167
69.6%
57.4%

93.0519
40.0%
67.2%

(Table C.2 cont'd).

Physician's age 93.6682 93.7640
45 or older 47.4% 62.5%
Less than 45 53.2% 59.1%

Political views 93.0086* NA
Conservative 26.7%

Moderate 48.5%
Liberal 84.6%

* Significance level of 9=<.05..

232

Table C.3.

Overall Agreement

Location
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical education
Educated in U.S.
Educated abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or less

Change practice setting
Yes, in last five years
No, in last five years

233

i989
51.7%

93.5992
55.2%
48.3%

93.9652
52.0%
51.4%

3.8115
53.5%
50.0%

93.8233
46.3%
50.0%

3.2916#
50.0%
40.0%
68.4%
36.4%

93..6274
55.6%
48.3%

93.5112#
62.5%
50.0%

93.7843
54.1%
57.9%

9=.1703
44.4%
62.5%

9=.2057
41.7%
58.3%

NA

Qualified physicians should be free to
establish practice without CON.

 

3.6560
54.5%

93.2287#
36.4%'
33.3%
60.0%
62.5%

93.9265
43.8%
45.2%

93.1516
70.0%
45.3%

93.0065*
35.0%
69.2%

93.1826
64.3%
44.2%

93.4958
43.5%
52.2%

93.9106
50.0%
48.2%

(Table C.3 cont'd.)

Physician's age
45 or older
Less than 45

Political views
Conservative
Moderate
Liberal

93.4636
44.4%
54.8%

93.0084*
86.7%
41.9%
36.4%

* Significance level of 93.05 or better.

:34:

234

Expected frequency <5 for at least one cell.

93.3961
54.8%
44.4%

NA

Table C.4.
regionalized.

Overall Agreement

Location
Metropolitan
Outstate

Years'practive
Seven or fewer
Eight or more

Medical education
Educated in U.S.
Educated abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or fewer

Change practice setting
Yes, in last five years
No, in last five years

235

Transplant facilities should be

i980
56.9%

93.7161
59.4%
54.8%

93.0784
69.0%
47.2%

93.0605
50.0%
75.0%

93.0157*
68.2%
30.8%

9=.0017*#
82.6%
36.4%
30.0%
72.7%

93.6179
47.4%
54.5%

9=.1347#
77.8%
.9%

9=.1722
63.4%
45.0%

9=.2092
50.0%
65.5%

9=.1053
43.5%
64.3%

NA

1987
69.9%

9=.4962
72.7%
65.8%

93.8545
70.0%
72.1%

93.0382*
79.6%
58.1%

93.0580#
73.8%
45.5%

93.0136*#
92.0%
41.7%
67.6%
70.0%

9=.7407
63.2%
67.6%

9=.7654#
66.7%
71.0%

93.0672
79.2%
60.0%

93.3285
81.3%
68.9%

93.6601
75.0%
70.2%

93.5920#
76.5%
69.8%

(Table C.4, cont'd.)

Physician's age
45 or older
Less than 45

Political views
Conservative
Moderate
Liberal

3:4

Significance level of 9=<.05.
Expected frequency <5 for at least one cell.

236

93.008O*
31.6%
67.4%

93.0480*
26.7%
59.4%
69.2%

93.3641
65.6%
75.0%

NA

Table C.5.

Overall Agreement

Location
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical Education
U.S. educated
Educated abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or fewer

Change practice setting
Yes, in last five years
No, in last five years

237

i980
74.6%

93.7640
75.8%
72.4%

9=.7198
76.7%
72.7%

93.6800#
72.7%
77.8%

93.5359#
72.7%
81.8%

9=.2293#
72.7%
75.0%
88.9%
54.5%

93.7640#
73.7%
77.4%

9=.0794#
100.0%
71.2%

9=.4701
70.0%
78.9%

93.2188
68.6%
82.1%

93.2683
82.6%
70.0%

NA

Favor limits to End-stage renal disease care.

1987
74.4%

93.8357
75.0%
73.0%

9=.2939#
83.3%
71.0%

93.7080
72.0%
75.9%

9=.4132#
75.4%
63.6%

9=.5700#
81.8%
66.7%
74.3%
60.0%

93.8211#
73.7%
76.5%

93.1584#
91.7%
72.6%

9=.3019
78.3%
67.7%

9=.3205
62.5%
75.0%

93.5889
69.6%
75.4%

9=.3087#
64.7%
75.8%

(Table C.5 cont'd.)

Physician's age 93.3903
45 or older 82.4%
Less than 45 71.7%

Political views 9=.5662#
Conservative 66.7%
Moderate 80.0%
Liberal 69.2%

# Expected frequency <5 for at least one cell.

238

93.6752
71.9%
76.1%

NA

Table C.6. Government model is good for other

catastrophic disease programs.

1239
Overall Agreement NA
Location
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical education
Educated in U.S.
Educated abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or fewer

Change practice setting
Yes, in last five years
No, in last five years

239

9=.1037*
65.0%
43.9%

93.2598
43.8%
57.1%

9=.9356
46.8%
45.5%

93.4936
63.6%
45.5%
45.5%
40.0%

9=.5215
50.0%
40.6%

3.8218
45.5%
49.2%

3.2388
55.8%
41.9%

9=.2847
37.5%
52.6%

93.0627
66.7%
42.9%

3.0244*
25.0%
56.7%

(Table C.6 cont'd.)

Physician's age 93.5089
45 or more 43.3%
Less than 45 51.1%

Political views NA
Conservative
Moderate
Liberal

* Significance level of =<.05..
# Expected frequency <5 for at least one cell.

240

 

Table C.7.
policy making.

Overall agreement

Location
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical education
Educated in U.S.
Educated abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings
Five or more
Four or fewer

Change practice setting
Yes, in last five years
No, in last five years

241

9=.7095

66.7%
47.1%
63.6%

9=.2377
45.0%
62.1%

93.4508#
44.4%
58.0%

93.8324
57.9%
55.0%

9=.9206
55.9%
57.1%

93.1671
68.2%
50.0%

NA

Favor increased consumer involvement in ESRD

i287
67.1%

9=.5445
75.6%
69.4%

93.0925#
89.5%
70.2%

93.0178
65.2%
89.7%

93.7155#
75.4%
70.0%

93.6946#
79.2%
72.7%
71.0%
88.9%

93.3588
72.2%
83.3%

93.6763#
66.7%
73.3%

93.6374
77.3%
72.4%

93.2409#
86.7%
71.9%

3.3129
82.6%
71.7%

9 .9724#
75.0%
74.6%

(Table C.7 cont'd.)

Physician's age
45 or older
Less than 45

Political views
Conservative
Moderate
Liberal

93.3592
47.1%
60.0%

93.9690
53.8%
54.5%
58.3%

* Significance level of 9=<.05..

=3:

242

Expected frequency <5 for at least one cell.

93.1480
65.5%
80.4%

NA

Table C.8. Renal physicians are influential in setting

renal policy.

Overall agreement

Location
Metropolitan
Outstate

Years' Practice
Seven or fewer
Eight or more

Medical education
Educated in U.S.
Educated abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Percent of income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings
Five or more
Four or fewer

Change practice setting
Yes, in last five years
No, in last five years

243

i9§0
34.5%

93.0023*
55.6%
15.4%

93.1880
23.8%
41.2%

93.0099:
43.6%
6.7%

9=.8573#
33.3%
30.6%

93.9188#
38.9%
36.4%
33.3%
25.0%

93.3216
45.0%
30.8%

9=.0385*#

0.0%
40.0%

93.2936
38.2%
23.5%

93.0372:
45.5%
18.2%

93.1882
23.8%
41.2%

NA

1231
NA

(Table C.8 cont'd.)

Physician's age
45 or older
Less than 45

Political views
Conservative
Moderate
Liberal

93.0550
52.9%
26.3%

93.0477*#
50.0%
20.0%
55.6%

* Significance level of 9=<.05..
# Expected frequency <5 for at least one cell.

244

Table C.9.

Overall agreement

Location
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical Education
Educated in U.S.
Educated abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or fewer

Change practice setting
Yes, in last five years
No, in last five years

245

1299
46.0%

93.6441
42.4%
48.3%

93.2676
53.3%
39.4%

93.1479
40.9%
61.1%

93.1348
38.6%
63.6%

9=.0639#
31.8%
41.7%
72.2%
36.4%

93.1864
57.9%
38.7%

938391#
50.0%
46.2%

93.3612
40.0%
52.6%

93.3366
51.4%
39.3%

93.0205:
65.2%
35.0%

NA

Age should limit eligibility for ESRD care.

1987
41.2%

93.2154
47.7%
34.2%

93.2939
31.6%
45.2%

93.4307
39.2%
48.3%

93.7057#
42.4%
36.4%

93.2889#
34.8%
41.7%
51.4%
20.0%

93.1248
63.2%
41.2%

93.0844

66.7%
39.7%

93.6014
44.7%
38.7%

93.1049
25.0%
47.5%

93.9709
43.8%
40.4%

93.0918
23.5%
46.2%

(Table C.9, cont'd.)

Physician's age
45 or older
Less than 45

Political views
Conservative
Moderate
Liberal

93.2156
58.8%
41.3%

* Significance level of 9=<.05..

=fl=

246

Expected frequency <5 for at least one

93.7687
43.8%
40.4%
NA
cell.

Table C.10. Government limits renal physician autonomy.

1990

Overall agreement NA

Location
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical Education
Educated in U.S.
Educated Abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or fewer

Change practice setting

Yes, in last five years
No, in last five years

247

1987
66.7%

3.0514
75.6%
55.3%

3.7487
70.0%
66.1%

93.5179
64.0%
71.0%

93.0912#
71.2%
45.5%

93.2804#
52.0%
75.0%'
70.6%
80.0%

93.2793
73.7%
58.8%

93.9140#
66.7%
68.3%

93.3494
61.7%
71.9%

93.9740
64.7%
65.6%

93.0085*
45.8%
75.9%

93.1227
82.4%
62.5%

(Table C 10 cont'd.)

Physician's age 93.1864
45 or older 75.8%
Less than 45 61.7%

Political views NA
Conservative
Moderate
Liberal

* Significance level of 9=<.05..
Expected frequency <5 for at least one cell.

=34:

248

Table C.11.
illnesses.

Overall agreement

Location
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical Education
Educated in U.S.
Educated Abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or fewer

Change practice setting
Yes, in last five years
No, in last five years

249

i980
63.2%

93.7254
69.7%
65.5%

93.4089
73.3%
63.6%

93.3575
65.9%
77.8%

93.7738#
68.2%
63.6%

9=..3804
63.6%
66.7%
83.3%
54.5%

93.8487
68.4%
71.0%

93.2106#
87.5%
65.4%

93.5047
65.0%
73.7%

93.1156
60.0%
78.6%

93.4643
73.9%
65.0%

NA

Favor limits to ESRD care based on other

1987
60.2%

93.4407
63.6%
55.3%

93.3529
68.4%
56.5%

93.6493#?
56.9%
62.1%

9=.5395#?
60.6%
45.5%

93.9439#
60.9%
58.3%
60.0%
50.0%

93.7404
63.2%
67.6%

93.3352#
75.0%
60.3%

93.7480
61.7%
58 O 1%

93.1111
43.8%
65.6%

93.9124
58.3%
59.6%

93.5835
52.9%
60.3%

(Table C.1l cont'd.)

Physician's age 93.7130 93.3414

45 or older 64.7% 53.1%

Less than 45 69.6% 63.8%
Political views 9=.9741#? NA

Conservative 66.7%

Moderate 70.0%

Liberal 69.2%

# Expected frequency <5 for at least one cell.

250

Table C.12. Large corporations limit physicians'

autonomy.

i980

Overall agreement NA

Location *
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical Education
Educated in U.S.
Educated Abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or fewer

Change practice setting
Yes, in last five years
No, in last five years

251

1987
52.2%

93.0871
60.0%
38.5%

93.1811
64.7%
45.8%

93.6143
47.2%
53.6%

93.1297#
53.7%
25.0%

93.6171#
42.9%
54.5%
50.0%
71.4%

93.0818
33.3%
61.5%

93.4884
40.0%
52.0%_

93.6488
48.8%
55.0%

93.2895
36.4%
54.0%

93.0056*
25.0%
62.2%

93.4201
61.5%
49.0%

(Table C 12 cont'd.)

Physician's age 93.2207
45 or older 55.6%
Less than 45 37.8%

Political views NA
Conservative
Moderate
Liberal

* Significance level of 9=<.05..
Expected frequency <5 for at least one cell.

=H=

252

 

Table C.13. Capitation affects selection of treatment

modality.

Overall agreement

Location
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical Education
Educated in U.S.
Educated Abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care

Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations

Five or more
Four or fewer

Professional meetings/year

Five or more
Four or fewer

Change practice setting
Yes, in last five years
No, in last five years

i989
NA

1987
63.0%

93.3379
59.1%
69.4%

93.6662
58.8%
64.5%

93.1660
70.2%
54.8%

93.0476*#
60.0%
90.9%

93.1294#
77.3%
75.0%
55.9%
40.0%

93.5342
61.1%
69.7%

93.6607#
58.3%
65.0%

93.0220:
72.7%
46.9%

93.2221
52.9%
69.0%

93.9685
63.6%
63.2%

93.4627
56.3%
66.1%

(Table C.13 cont'd.)

Physician's age 93.2050
45 or older 71.9%
Less than 45 57.8%

Political views NA
Conservative
Moderate
Liberal

* Significance level of 9=<.05..
Expected frequency <5 for at least one cell.

it

254

Table C.14. Medical professionals should plan ESRD

program.

Overall agreement

Location
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical Education
Educated in U.S.
Educated Abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or fewer

Change practice setting
Yes, in last five years
No, in last five years

1989
95.4%

93.5731#
93.8%
96.8%

93.6483#
96.7%
94.3%

93.2317#
93.2%
100.0%

93.5919#
95.6%
91.7%

93.1248#
100.0%
100.0%

87.0%
100.0%

93.4436#
100.0%
97.0%

93.4687#
100.0%
94.4%

93.2148#
92.7%
100.0%

93.1114#
91.7%
100.0%

93.0205*#

87.5%
100.0%

NA

1987
NA

(Table C 14 cont'd).

Physician's age 93.2724#
45 or older 100.0%
Less than 45 93.6%
Political views 93.0018%*#
Conservative 100.0%
Moderate 100.0%
Liberal - 75.0%

* Significance level of 9=<.05..
# Expected frequency <5 for at least one cell.

256

Table C.15. Medical professionals should administer the
ESRD program.

1222 1221
Overall agreement 89.7% NA
Location 9=.6942#
Metropolitan 90.9%
Outstate 93.5%
Years' practice 9=.7889#
Seven or fewer 93.3%
Eight or more 91.7%
Medical Education 93.1208#
Educated in U.S. 88.9%
Educated Abroad 100.0%
Specialty 93.8977#
Nephrologist 93.3%
Transplant Surgeon 92.3%
Practice Organization 93.7721#
Full-time Faculty 91.3%
Multi-Specialty 91.7%
Single-Specialty 90.0%
Solo Practice 100.0%
Setting of Practice 93.2872#
Office 90.0%
Hospital 97.0%
For-profit inpatient care 93.3434#
Over half-time 100.0%
Half-time or less 90.7%
Income in salary 93.5408#
Over half 90.5%
Half or less 95.0%
Professional organizations 93.2619#
Five or more 89.2%
Four or fewer 96.6%
Professional meetings/year 93.2531#
Five or more . 87.5%
Four or fewer 95.2%
Change practice setting NA

Yes, in last five years
No, in last five years

257

(Table C 15 cont'd.)

Physician's age
45 or older
Less than 45

Political views
Conservative
Moderate
Liberal

93.6517#
94.7%
91.5%

9=.5657#
93.3%
93.9%
84.6%

# Expected frequency <5 for at least one cell.

258

Table C.16.
therapy selection.

Overall agreement
Have enough influence
Should influence less

Location
Metro
Outstate

Years' practice
Seven or fewer
Eight or more

Medical Education
Educated in U.S.
Educated Abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or fewer

259

Surgeon should have more influence on

1222

12.7%
61.9%
25.4%

93.0567#
3.2%
23.3%

9=.4554#
11.1%
13.9%

9=.4173#
9.3%
21.1%

93.0106*#
7.0%
38.5%

3.0855#

27.3%

11.1%
4.8%
0.0%

93.1028#
0.0%
20.0%

93.9754#
12.5%
13.5%

93.4444#
17.1%
5.6%

93.9567#
13.5%
11.5%

93.7941#
12.5%
12.8%

(Table C.16 cont'd.)

Change practice setting
Yes, in last five years
No, in last five years

Physician's age
45 or older
Less than 45

Political views
Conservative
Moderate
Liberal

* Significance level of 9=<.05.

NA

9=.9432#
10.5%
13.6%

93.8518#
6.7%

15.2%
9.1%

# Expected frequency <5 for at least one cell.

260

Table C.17. Nephrologist should have more influence in

therapy selection.

Overall agreement

Location
Metro
Outstate

Years' practice
Seven or fewer
Eight or more

Medical Education
Educated in U.S.
Educated Abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or fewer

Change practice setting
Yes, in last five years
No, in last five years

1222 1221

13.8% NA

9=.4271#
18.8%
9.7%

93.4130#
20.0%
8.6%

93.9285#
14.0%
14.3%

93.0784#
15.6%
0.0%

93.7376#

13.0%
9.1%

20.0%
9.1%

93.3283#
10.5%
12.1%

93.2081#
33.3%
11.3%

93.2510#
11.9%
21.1%

9=.0293*#
5.6%
24.1%

93.2070#
12.5%
14.6%

NA

(Table C.17, cont'd).

Physician's age 93.6347#
45 or older 16.7%
Less than 45 12.8%

Political views 9=.3736#
Conservative 20.0%
Moderate 8.8%
Liberal 9.1%

* Significance level of 9=<.05..
# Expected frequency <5 for at least one cell.

262

Table C.18.
patient care.

i290
Overall agreement NA
disagreement
indecision
Location
Metropolitan
Outstate

Years' practice
Seven or less
Eight or more

Medical Education
Educated in U.S.
Educated Abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year

Five or more
Four or fewer

263

Large corporations have positive impact on

l9§7

19.0%
44.0%
36.9%

93.6929
18.2%
20.5%

9=.4399#
21.1%
15.0%

93.9983
19.6%
20.0%

9=.1313#
24.2%
0.0%

9=.1757#
28.0%
16.7%
17.1%
11.1%

93.0780#
27.8%
5.7%

9=.6047#
8.3%
20.6%

93.5329
22.9%
12.9%

93.2079#
23.5%
16.4%

9=.6914#
25.0%
17.2%

(Table C.18 cont'd.)

Change practice setting 9=.0097*#
Yes, in last five years 00.0%
No, in last five years 23.1%
Physician's age 93.7851
45 or older 15.2%
Less than 45 19.6%
Political views NA
Conservative
Moderate
Liberal

* Significance level of 9=<.05..
# Expected frequency <5 for at least one cell.

264

Table C.19. Should use more transplantation.

Overall agreement

Location
Metropolitan
Outstate

Years' practice _
Seven or fewer
Eight or more

Medical Education
Educated in U.S.
Educated Abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or fewer

Change practice setting

Yes, in last five years
No, in last five years

265

1222

93.0750

100.0%
89.3%

9=.6810

96.2%
93.8%

93.2083

97.4%
89.5%

93.3284

92.5%
100.0%

93.7903

95.2
100.0
94.1
90.0

93.6774
94.1%
96.7%

93.4139
88.9%
95.7%

93.8679
94.9%
93.8%

93.3260
97.1%
91.3%

93.7714
95.8%
94.1%

NA

(Table C.19 cont'd.)

Physician's age 93.7615
45 or older 93.3%
Less than 45 95.3%

Political views 93.5923
Conservative 100.0%
Moderate ' 94.1%
Liberal 90.0%

# Expected frequency <5 for at least one cell.

266

Table C.20.
setting policy.

Overall agreement
Current influence good
Should have less influence

Location
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical Education
Educated in U.S.
Educated Abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year

Five or more
Four or fewer

267

ESRD network should have more influence in

i989

25.9%
64.8%
14.8%

93.2026#
17.2%
33.3%

93.0108*#
12.0%
34.4%

93.7853#
22.5%
25.0%

93.7282#
25.0%
25.0%

93.1543#
36.8%
36.4%
11.8%
10.0%

9=.7414#
15.8%
25.0%

93.0741#
12.5%
28.3%

9=.2395#
27.0%
18.8%

93.2453#
32.4%
13.0%

42.9%
13.9%

(Table C.20 cont'd.)

Change practice setting
Yes, in last five years
No, in last five years

Physician's age
45 or older
Less than 45

Political views
Conservative
Moderate
Liberal

* Significance level of 9=<.05.
Expected frequency <5 for at least one cell.

:3:

268

NA

9=.504l#
31.3%
22.0%

9=.5447#
15.4%
27.3%
37.5%

Table C.21.
decision.

Overall agreement

Location
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical education
Educated in U.S.
Educated abroad

Specialty
Nephrologist
Transplant surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or fewer

Change practice setting
Yes, in last five years
No, in last five years

269

1980
81.3%

93.1985
87.1%
74.2% .

93.8098
80.0%
82.4%

9=.5769#
79.1%
85.0%

9=.2158#
76.7%
92.3%

93.4961#
90.9%
72.7%
75.0%
81.8%

9=.4905#
76.2%
83.9%

93.7041#
75.0%
80.8%

93.8271#

81.0%
83.3%

93.8718
80.6%
82.1%

93.3810#
87.0%
78.0%

NA

Nephlogist has most influence on treatment

1987
70.2%

93.1433
77.8%
63.2%

93.5171
65.0%
72.6%

93.3636
74.0%
64.5%

93.0235*#
66.7%

100.0%

93.4654#
76.0%'
83.3%
61.8%
70.0%

93.9103
63.2%
64.7%

93.914o#
66.7%
68.3%

93.3043
66.7%
77.4%

93.9627#
68.8%
69.4%

93.1067
83.3%
65.5%

93.9823
70.6%
70.3%

(Table C. 21 cont'd.)

Physicians' age
45 or older
Less than 45

Political views
Conservative
Moderate
Liberal

93.7894#
83.3%
80.4%

9=.4449#
78.6%
75.8%
92.3%

* Significance level of 9=<.05..

=84:

270

Expected frequency <5 for at least one cell.

93.0614
81.8%
62.5%

NA

Table C.22.
therapy selection.

Overall agreement

Location
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical Education
Educated in U.S.
Educated Abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-prdfit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more .
Four or fewer

Change practice setting
Yes, in last five years
No, in last five years

271

1980
43.8%

931.0000
45.2%
45.2%

93.2833
50.0%
36.7%

93.5892
40.5%
47.6%

93.8632
44.4%
41.7%

9=.6078#
52.2%
45.5%
31.6%
45.5%

93.5104
38.9%
48.5%

93.9243#
44.4%
46.2%

93.0307*
52.4%
22.2%

93.0077*
58.3%
25.0%

93.0685
58.3%
35.0%

NA

Patient should have more influence in

1987

 

38.6%

93.3144
44.2%
33.3%

9=.0270*
60.0%
32.3%

93.047o*
48.0%
25.8%

93.4984#
34.8%
45.5%

93.1869
56.0%
33.3%
28.6%
40.0%

93.4075
36.8%
48.6%

93.2472#
25.0%
42.9%

93.3071
43.8%
32.3%

93.6998
41.2%
36.1%

93.7524
41.7%
37.9%

93.0116*
64.7%
31.3%

(Table C.22 cont'd.)

Physician's age
45 or older
Less than 45

Political views
Conservative
Moderate
Liberal

* Significance level of

=32:

93.7483
47.1%
42.6%

93.4866#
28.6%
47.1%
45.5%

9=<.05..

272

Expected frequency <5 for at least one cell.

93.7094
37.5%
41.7%

NA

Table C.23. Believe supply

Overall agreement

Location
Metropolitan ‘
Outstate

Years' practice
Seven or fewer
Eight or more

Medical Education
Educated in U.S.
Educated Abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or fewer

Change practice setting
Yes, in last five years
No, in last five years

273

1989
95.6%

93.3135#
96.9%
100.0%

9=.2843#
96.8%
100.0%

9=.1446#
100.0%
95.2%

931.000#
100.0%
100.0%

93.5938#

95.7%
100.0%
100.0%
100.0%

93.4319#
100.0%
97.0%

93.6778#
100.0%
98.1%

93.5028#
97.7%
100.0%

93.2550#
100.0%
96.6%

93.4462#
100.0%
97.6%

NA

of ESRD care is adequate.

1221
78.8%

93.9831
81.4%
81.6%

9=.7340#
80.0%
83.3%

93.7600
83.3%
80.6%

93.1033#
80.0%
100.0%

93.3791#
88.0%
82.9%
72.7%
70.0%

93.3432#
77.8%
87.9%

93.0939#
100.0%
79.0%

93.1908#
86.7%
75.0%

93.844l#
81.3%
83.3%

93.0492*#
95.7%
77.2%

93.0785#
66.7%
85.9%

(Table C.23 cont'd.)

Physician's age 9=5372# 93.1127#
45 or older 100.0% 73.3%
Less than 45 97.9% 87.5%

Political views 931.0000# NA
Conservative 100.0%

Moderate ' 100.0%
Liberal 100.0%

* Significance level of 9=<.05..
# Expected frequency <5 for at least one cell.

274

Table C.24. Patients are referred to specialists soon

enough.
1222
Overall agreement NA
Location
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical Education
Educated in U.S.
Educated Abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or fewer

Change practice setting
Yes, in last five years
No, in last five years

275

i987
19.7%

93.6427
22.0%
17.6%

93.2665#
11.1%
23.2%

93.6227
18.6%
23.3%

93.2553#
15.3%
30.0%

9=.4389#
22.7%
36.4%
16.7%
10.0%

93.7267#
17.6%
21.9%

93.8496#
20.7%
18.2%

93.8830
21.4%
20.0%

93.4051#
13.3%
23.2%

93.4032#
17.6%

93.1422#

6.7%
23.7%

 

(Table C.24 cont'd.)

Physician's age 93.2466
45 or older 27.6%
Less than 45 16.3%

Political views NA
Conservative
Moderate
Liberal

# Expected frequency <5 for at least one cell.

276

Table C.25. Capitation has positive effect on service

to patients.

Overall agreement
Disagreement
Undecided

Location NA
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical Education
Educated in U.S.
Educated Abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year

Five or more
Four or fewer

277

1987

19.3%
47.0%
33.7%

93.3485
15.9%
23.7%

93.8974#
16.7%
20.6%

93.4676
22.4%
16.1%

93.4246#
19.7%
27.3%

93.5221#
21.7%
16.7%
22.9%
10.0%

93.7239#
21.1%
26.5%

93.5165#
8.3%
22.6%

93.9702
19.6%
18.8%

9 .1421#
35.3%
16.7%

93.4952#
12.5%
22.8%

(Table C.25 cont'd.)

Change practice setting
Yes, in last five years
No, in last five years

Physician's age
45 or older
Less than 45

Political views
Conservative
Moderate
Liberal

# Expected frequency <5 for at least one cell.

278

93.1821#
35.3%
15.9%

93.7851
15.2%
19.6%

NA

Table C.26. ESRD knowledge in the U.S. is superior to

that abroad.

Overall agreement

Location
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical Education
Educated in U.S.
Educated Abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or fewer

Change practice setting
Yes, in last five years
No, in last five years

279

1980

83.8%

93.0241*#

85.2%
100.0%

9 .8649#
92.9%
93.9%

93.7667#
92.7%
94.7%

93.0807#
97.5%
84.6%

93.7486#
90.5%
90.9%
94.4%
100.0%

93.1689#
100.0%
90.6%

93.4377#
100.0%
92.0%

93.1588#
89.7%
100.0%

93.0745#
88.6%
100.0%

93.0059*#

81.8%
100.0%

NA

..1ux j'j'lrl 7-1w

 

 

(Table C.26 cont'd.)

Physician's age 93.8947#
45 or older 94.1%
Less than 45 93.2%

Political views 9=.9734#
Conservative ‘ 92.3%
Moderate 93.5%
Liberal 91.7%

* Significance level of 9=<.05.
Expected frequency <5 for at least one cell.

at:

280

Table C.27.

Overall agreement

Location
Metropolitan
Outstate

Years' practice
Seven or fewer
Eight or more

Medical Education
Educated in U.S.
Educated Abroad

Specialty
Nephrologist
Transplant Surgeon

Practice Organization
Full-time Faculty
Multi-Specialty
Single-Specialty
Solo Practice

Setting of Practice
Office
Hospital

For-profit inpatient care
Over half-time
Half-time or less

Income in salary
Over half
,Half or less

Professional organizations
Five or more
Four or fewer

Professional meetings/year
Five or more
Four or fewer

Change practice setting
Yes, in last five years
No, in last five years

281

i980
92.7%

93.0760
100.0%
90.6%

93.0952
100.0%
91.4%

93.9690
95.5%
95.2%

93.3636
93.5%
100.0%

93.5987
95.7%
91.7%
100.0%
90.9%

93.7153
95.0%
97.0%

93.4687
100.0%
94.4%

93.1912
97.6%
90.0%

93.6661
94.4%
96.7%

93.9111
95.8%
95.2%

NA

Favor more use of home hemodialysis.

i987
78.8%

93.0262*
93.0%
75.0%

93.3314
78.9%
87.9%

93.8195
84.8%
86.7%

93.1260
82.0%

100.0%

93.2666
87.5%

100.0%

83.9%
70.0%

93.8847
88.9%
87.5%

93.1403

100.0%

83.1%

93.6446
86.7%
82.8%

93.7452
87.5%
84.2%

93.8389
87.0%
85.2%

93.5843

81.3%
86.7% 81

Table C.27 (Cont.d)

Physician's age 93.2776 . 93.8078
45 or older 100.0% 84.4%
Less than 45 93.8% 86.4%

Political views 93.6749
Conservative 93.3%

Moderate 94.1%
Liberal 100.0%

# Expected frequency <5 for at least one cell.

282

APPENDIX D

Appendix D 1. Letter to renal physicians requesting
their response to the mailed questionnaire.

Dear Dr. (Name):

Enclosed is a questionnaire about renal physicians'
beliefs and opinions on health policy that I am asking
you to respond to. It should take only about fifteen
minutes of your time. I am a Ph.D. candidate in medical
sociology, and I would like very much to include your
responses in this study. This research is in part a
follow-up to a survey conducted several years ago by
Dr. Elianne Riska.

There are several points about your participation
in this study that I would like to mention.

First, since there are only about one hundred renal
physicians in the state, a high response rate is
necessary for this study to reflect accurately the
opinions of renal physicians in the state. All answers
are anonymous and confidential. Your questionnaire will
be identified only by a number, to enable followup on
unreturned questionnaires. The analysis will not
identify individual physicians, individual hospitals or
any other ESRD facilities.

Second, please answer the questionnaire as
completely as possible. If you have questions
concerning the study or the questionnaire, please
contact me at (517) 351-6299 or at (517) 355-0149.

Thank you for your cooperation. A summary of the
results of this study will be sent to you on your
request; just mark the appropritae space on the enclosed
questionnaire.

Sincerely,

Nancy Buffenbarger

283

 

Appendix D 2. Followup letter requesting physicians to
return questionnaire.

Dear Dr. (Name):

Recently I mailed you a questionnaire as part of a
survey of the opinions of renal physicians on renal
policy issues. If your response is not already in the
mail, this is a reminder and an earnest request that you
return the questionnaire at your early convenience. I
would very much like to include your opinions in the
study results.

If your questionnaire has been misplaced, I would
be glad to send you another copy. Please call (517)
355-6640, give your name and address, and I will send a
questionnaire and a stamped return envelope.
Sincerely,

Nancy Buffenbarger

. ' F

r—..t’\“\l"‘.- w l

 

284

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