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Formal Analysis, Policy Formulation, and

End-Stage Renal Disease

April 1981

NTIS order #PB81-209769


Library of Congress Catalog Card Number 80-600161

For sale by the Superintendent of Documents,


U.S. Government Printing Office, Washington, D.C. 20402
Foreword

This case study is one of 17 studies comprising Background Paper #2 for OTA’s
assessment, The Implications of Cost-Effectiveness Analysis of Medical Technology.
That assessment analyzes the feasibility, implications, and value of using cost-effec-
tiveness and cost-benefit analysis (CEA/CBA) in health care decisionmaking. The ma-
jor, policy-oriented report of the assessment was published in August 1980. In addition
to Background Paper #2, there are four other background papers being published in
conjunction with the assessment: 1) a document which addresses methodological
issues and reviews the CEA/CBA literature, published in September 1980; 2) a case
study of the efficacy and cost-effectiveness of psychotherapy, published in October
1980; 3) a case study of four common diagnostic X-ray procedures, to be published in
summer 1981; and 4) a review of international experience in managing medical tech-
nology, published in October 1980. Another related report was published in
September of 1979: A Review of Selected Federal Vaccine and Immunization Policies.
The case studies in Background Paper #2; Case Studies of Medical Technologies
are being published individually. They were commissioned by OTA both to provide
information on the specific technologies and to gain lessons that could be applied to
the broader policy aspects of the use of CEA/CBA. Several of the studies were specifi-
cally requested by the Senate Committee on Finance.
Drafts of each case study were reviewed by OTA staff; by members of the ad-
visory panel to the overall assessment, chaired by Dr. John Hogness; by members of
the Health Program Advisory Committee, chaired by Dr. Frederick Robbins; and by
numerous other experts in clinical medicine, health policy, Government, and econom-
ics. We are grateful for their assistance. However, responsibility for the case studies re-
mains with the authors.

JOHN H. GIBBONS
Director

111
Advisory Panel on The Implications of
Cost-Effectiveness Analysis of Medical Technology

John R. Hogness, Panel Chairman


President, Association of Academic Health Centers

Stuart H. Altman Sheldon Leonard


Dean Manager
Florence Heller School Regulatory Affairs
Brandeis University General Electric Co.

James L. Bennington Barbara J. McNeil


Chairman Department of Radiology
Department of Anatomic Pathology and Peter Bent Brigham Hospital
Clinical Laboratories
Childrens Hospital of San Francisco Robert H. Moser
Executive Vice President
John D. Chase American College of Physicians
Associate Dean for Clinical Affairs
University of Washington School of Medicine Frederick Mosteller
Chairman
Joseph Fletcher Department of Biostatistics
Visiting Scholar Harvard University
Medical Ethics
School of Medicine Robert M. Sigmond
University of Virginia Advisor on Hospital Affairs
Blue Cross and Blue Shield Associations
Clark C. Havighurst
Professor of Law Jane Sisk Willems
School of Law VA Scholar
Duke University Veterans Administration
OTA Staff for Background Paper #2

Joyce C. Lashof, Assistant Director, OTA


Health and Life Sciences Division

H. David Banta, Health Program Manager

Clyde J. Behney, Project Director


Kerry Britten Kemp, * Editor
Virginia Cwalina, Research Assistant
Shirley Ann Gayheart, Secretary
Nancy L. Kenney, Secretary
Martha Finney, * Assistant Editor

Other Contributing Staff

Bryan R. Luce Lawrence Miike Michael A. Riddiough


Leonard Saxe Chester Strobel*

OTA Publishing Staff

John C. Holmes, Publishing Officer


John Bergling* Kathie S. Boss Debra M. Datcher
Patricia A. Dyson* Mary Harvey* Joe Henson

● OTA contract personnel


Preface

This case study is one of 17 topics being is- examples with sufficient evaluable litera-
sued that comprise Background Paper #2 to the ture.
OTA project on the Implicatiom of Cost-Effec-
On the basis of these criteria and recommen-
tiveness Analysis of Medical Technology. * The
dations by panel members and other experts,
overall project was requested by the Senate
OTA staff selected the other case studies. These
Committee on Labor and Human Resources. In
16 plus the respiratory therapy case study re-
all, 19 case studies of technological applications
quested by the Finance Committee make up the
were commissioned as part of that project.
17 studies in this background paper.
Three of the 19 were specifically requested by
the Senate Committee on Finance: psychother- All case studies were commissioned by OTA
apy, which was issued separately as Back- and performed under contract by experts in aca-
ground Paper #3; diagnostic X-ray, which will demia. They are authored studies. OTA sub-
be issued as Background Paper #.5; and respira- jected each case study to an extensive review
tory therapies, which will be included as part of process. Initial drafts of cases were reviewed by
this series. The other 16 case studies were se- OTA staff and by members of the advisory
lected by OTA staff. panel to the project. Comments were provided
to authors, along with OTA’s suggestions for
In order to select those 16 case studies, OTA,
revisions. Subsequent drafts were sent by OTA
in consultation with the advisory panel to the
to numerous experts for review and comment.
overall project, developed a set of selection
Each case was seen by at least 20, and some by
criteria. Those criteria were designed to ensure
40 or more, outside reviewers. These reviewers
that as a group the case studies would provide:
were from relevant Government agencies, pro-
● examples of types of technologies by func- fessional societies, consumer and public interest
tion (preventive, diagnostic, therapeutic, groups, medical practice, and academic med-
and rehabilitative); icine. Academicians such as economists and de-
● examples of types of technologies by physi- cision analysts also reviewed the cases. In all,
cal nature (drugs, devices, and procedures); over 400 separate individuals or organizations
● examples of technologies in different stages reviewed one or more case studies. Although all
of development and diffusion (new, emerg- these reviewers cannot be acknowledged indi-
ing, and established); vidually OTA is very grateful for- their com-
● examples from different areas of medicine ments and advice. In addition, the authors of
(such as general medical practice, pedi- the case studies themselves often sent drafts to
atrics, radiology, and surgery ); reviewers and incorporated their comments.
● examples addressing medical problems that
These case studies are authored works
are important because of their high fre-
commissioned by OTA. The authors are re-
quency or significant impacts (such as
sponsible for the conclusions of their spe-
cost );
cific case study. These cases are not state-
● examples of technologies with associated
ments of official OTA position. OTA does
high costs either because of high volume
not make recommendations or endorse par-
(for low-cost technologies) or high individ-
ticular technologies. During the various
al costs;
stages of the review and revision process,
● examples that could provide informative
therefore, OTA encouraged the authors to
material relating to the broader policy and
present balanced information and to recog-
methodological issues of cost-effectiveness
nize divergent points of view. In two cases,
or cost-benefit analysis (CEA/ CBA); and
OTA decided that in order to more fully
present divergent views on particular tech-
nologies a commentary should be added to
the case study. Thus, following the case
tive. The reader is encouraged to read this study
studies on gastrointestinal endoscopy and
in the context of the overall assessment’s objec-
on the Keyes technique for periodontal dis-
tives in order to gain a feeling for the potential
ease, commentaries from experts in the ap-
role that CEA/CBA can or cannot play in health
propriate health care specialty have been care and to better understand the difficulties and
included, followed by responses from the
complexities involved in applying CEA/CBA to
authors.
specific medical technologies.
The case studies were selected and designed to
The 17 case studies comprising Background
fulfill two functions. The first, and primary,
Paper #2 short titles and their authors are:
purpose was to provide OTA with specific in-
formation that could be used in formulating Artificial Heart: Deborah P. Lubeck and John P.
general conclusions regarding the feasibility and Bunker
implications of applying CEA/CBA in health Automated Multichannel Chemistry Analyzers:
care. By examining the 19 cases as a group and Milton C. Weinstein and Laurie A. Pearlman
looking for common problems or strengths in Bone Marrow Transplants: Stuart O. Schweitz-
the techniques of CEA/CBA, OTA was able to er and C. C. Scalzi
better analyze the potential contribution that Breast Cancer Surgery: Karen Schachter and
these techniques might make to the management Duncan Neuhauser
of medical technologies and health care costs Cardiac Radionuclide Imaging: William B.
and quality. The second function of the cases Stason and Eric Fortess
was to provide useful information on the spe- Cervical Cancer Screening: Bryan R. Luce
cific technologies covered. However, this was Cimetidine and Peptic Ulcer Disease: Harvey V.
not the major intent of the cases, and they Fineberg and Laurie A. Pearlman
should not be regarded as complete and defini- Colon Cancer Screening: David M. Eddy
tive studies of the individual technologies. In CT Scanning: Judith L. Wagner
many instances the case studies do represent ex- Elective Hysterectomy: Carol Korenbrot, Ann
cellent reviews of the literature pertaining to the B. Flood, Michael Higgins, Noralou Roos,
specific technologies and as such can stand on and John P. Bunker
their own as a useful contribution to the field. In End-Stage Renal Disease: Richard A. Rettig
general, though, the design and the funding Gastrointestinal Endoscopy: Jonathan A. Show-
levels of these case studies was such that they stack and Steven A. Schroeder
should be read primarily in the context of the Neonatal Intensive Care: Peter Budetti, Peggy
overall OTA project on CEA/CBA in health McManus, Nancy Barrand, and Lu Ann
care. Heinen
Nurse Practitioners: Lauren LeRoy and Sharon
Some of the case studies are formal CEAs or
Solkowitz
CBAs; most are not. Some are primarily con-
Orthopedic Joint Prosthetic Implants: Judith D.
cerned with analysis of costs; others are more
Bentkover and Philip G. Drew
concerned with analysis of efficacy or effec-
Periodontal Disease Interventions: Richard M.
tiveness. Some, such as the study on end-stage
Scheffler and Sheldon Rovin
renal disease, examine the role that formal
Selected Respiratory Therapies: Richard M.
analysis of costs and benefits can play in policy
Scheffler and Morgan Delaney
formulation. Others, such as the one on breast
cancer surgery, illustrate how influences other These studies will be available for sale by the
than costs can determine the patterns of use of a Superintendent of Documents, U.S. Govern-
technology. In other words, each looks at eval- ment Printing Office, Washington, D.C. 20401.
uation of the costs and the benefits of medical Call OTA’s Publishing Office (224-8996) for
technologies from a slightly different perspec- availability and ordering information.
Case Study #1
Formal Analysis, Policy Formulation,
and End-Stage Renal Disease

Richard A. Rettig, Ph. D.


The Rand Corp.
Santa Monica, Calif.

AUTHOR’S ACKNOWLEDGMENTS
The author thanks the following individuals for helpful comments on an earlier
draft: Robert W. Berliner, M. D.; Benjamin T. Burton, Ph. D.; Nancy Boucot Cum-
mings, M. D.; William de Cesare, M. D.; Joseph L. de la Puente; Richard B. Freeman,
M. D.; Carl W. Gottschalk, M. D.; Thomas J. Kennedy, Jr., M. D.; Herbert E. Klar-
man, Ph. D.; Irving J. Lewis; Charles L. Plante; George E. Schreiner, M. D.; Donald
W. Seldin, M. D.; and WiIliam H. Stewart, M.D. Remaining errors of fact are the re-
sponsibility of the author. Interpretations, of course, are wholly the author’s respon-
sibility.
Contents
Page
Introduction. , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
The ESRD Patient Population. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Formal Analysis Literature Pertaining to ESRD . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Formal Analysis and ESRD Policy Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Report of the Committee on Chronic Kidney Disease . . . . . . . . . . . . . . . . . . . 6
Kidney Disease Program Analysis: A Report to the Surgeon General . . . . . . . 11
The Policy and Eureaucratic Contexts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Policy and Program Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Table No. Page


1. Age Distribution of Dialysis Patients and Deaths in PHS-Supported
Programs, March 1960-March 1967 . . . . 4
2. Age Distribution of Dialysis Patients and Deaths in VA
March 1963-March 1967. . . . . . . . . . . . . 4
3. Patients Alive on Dialysis in the United States, 1970-76 5
4. Total Kidney Transplants Worldwide by Year, 1967-76 5
5. Medicare ESRD Patient Population, 1973-78 . . . . . . . . 5
6. Predicted Caseload in Patient Years of Dialysis Under Varying Levelsof
Expected Cases of Chronic Uremia and Differing Amounts of
Transplantation, 3968-77 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
7. Increased Life-Years and Costs per Additional Life-Year by Means of
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
8. Total Estimated Federal and Non-Federal Patient Care Costs of a National
Dialysis and Transplantation Program 12
9. HEW Cost Summary . . . . . . . . . . . . . 14
10. Program Benefits . . . . . . . . . . . . . . . . 15

FIGURE

Figure No. Page


1. Effect of the Advancing State of the Art on Future Program Composition . . . . . 16
Case Study #1:
Formal Analysis, Policy Formulation,
and End-Stage Renal Disease
Richard A. Rettig, Ph. D.
The Rand Corp.
Santa Monica, Calif.

INTRODUCTION
The past two decades have witnessed increas- This case study examines two instances of the
ing use of formal analysis in Federal Govern- use of formal analysis in the formulation of Fed-
ment policymaking. Most strongly identified eral Government policies toward ESRD. 1 Its fo-
with the Department of Defense in the early cus is on the work of two committees, whose re-
1960’s (8,15,16), formal analysis has now been ports were an integral part of the ESRD policy
extended to all areas of domestic public policy, formulation process in 1966 and 1967: 1) the
including health (35,36). The use of formal anal- Gottschalk committee, advisory to the U.S. Bu-
ysis has also been extended from policymaking reau of the Budget (BOB), and 2) the Burton
to program evaluation (44). In this case study, committee, internal to the Public Health Service
we analyze two instances of the use of formal (PHS). Several questions are addressed. What
analysis in the formulation of Federal Govern- factors gave rise to the demand for formal anal-
ment policy for end-stage renal disease (ESRD). ysis within the policy process? What were the
purposes of and constraints on the analyses?
The term formal analysis, as used in this
What did the analyses conclude? How were the
study, refers to any explicitly analytical means
results of these analyses used? What general les-
of systematically examining the social costs and
sons can be drawn from this experience?
benefits of alternative policies for the purpose of
choosing a preferred alternative in light of an a Background information about ESRD is pre-
priori normative decision rule. Included are sented in the first section below. The subsequent
cost-benefit analysis (CBA), cost-effectiveness section contains a review of the literature per-
analysis (CEA), risk-benefit analysis, technol- taining to ESRD, emphasizing the two major
ogy assessment, and other comparable means of analytical studies—the Gottschalk report and
analysis used in decisionmaking. the Burton report—which were pertinent to the
policy formulation process. The role that those
Much attention is given in the literature about
two studies played in that process is then ex-
formal analysis for policymaking to the general
amined in the next section. In the final section,
techniques and limits of analysis (23,30) or the
we develop our conclusions.
results and implications of particular studies. Of
critical importance, as well, however, are the in-
stitutional factors encouraging or inhibiting the
use of formal analysis in policymaking. These
institutional factors are a major concern of this ‘The general evolutlon of Federal policy in the area ot ESRD has
case study. been analyzed elsewhere (32, 33).
THE ESRD PATlENT POPULATION
Treatment of ESRD by hemodialysis began in higher patient mortality rate, fewer younger pa-
early 1960. By early 1967, according to esti- tients, and fewer elderly patients.
mates prepared by an advisory committee to
Time series data on dialysis began to be col-
BOB, approximately 750 to 1,000 patients had
lected in 1970. Data from the National Dialysis
been treated by dialysis (31).
Registry 2 are presented in table 3. These data
Data on patients treated in PHS-supported show: 1) the proportion of women in the total
dialysis programs from March 1960 to March patient population increased from 32 percent in
1967 are presented in table 1. These data indi- 1970 to 40 percent in 1976; 2) the average age
cate that roughl y 90 percent of these patients climbed steadily for both in-center and home di-
were distributed across the four age groups from alysis patients; and 3) the proportion of home
15 to 54 years. They also show an overall mor- patients to total dialysis patients climbed to ap-
tality rate for these patients of 17 percent, with
considerable variation in the mortality rates for ‘The National Dialysis Registry was managed by the Research
Triangle Institute from 1967 through 1976, under contract to the
specific age groups. National Institutes of Health (NIH). The National Dialysis Regis-
try was known to underreport the total U.S. dialysis population,
Table 2 presents similar data for patients because participation in the Registry was voluntary. Since the au-
receiving dialysis in Veterans Administration thorization of the medicare ESRD program in late 1972 created the
(VA) hospitals from March 1963 through March expectation that both the National Dialysis Registry and the Hu-
man Renal Transplant Registry would be merged into a single sys-
1967. By comparison with the PHS data in table tem, it can be assumed that underreportin g was exacerbated from
1, the data on these patients reveal a slightly 1974 onward.

Table 1 .—Age Distribution of Dialysis Patients and Deaths in


PHS-Supported Programs, March 1960-March 1967
-.
-
P e r c e n t Number Percent
Age group All patients total patients deceased deceased
-
Under 15 . . . . . . . . 3 ‘-1 .2- 0 0.0-
15-24 ., ., ., 42 17.0 7 16.7
25-34 ., 69 27.9 9 13.0
35-44 . . . . . . . . . 61 24.7 7 11.4
45-54 ... 52 21.1 13 25.0
55-64 . . . . . . . . . 18 7.3 5 27.8
Over 65 . . . . . . 2 0.8 1 50.0
Total . . ... . . 247 ‘1 00.0 ‘42-” ‘- ‘ - 1-7,0

SOURCE Report of the Committee on Chronic Kidney Disease. September 1967

Table 2.—Age Distribution of Dialysis Patients and Deaths in VA Hospitals


March 1963-March 1967

Percent Number Percent -

Age group All patients total patients deceased deceased


—-
U n d e r 1 5 , 0 0.0 0 0.0 ‘-
15-24 . . . . . . 8 3.5 2 25.0
25-34 . . . ... 54 23.4 9 16.7
35-44 . . ., 99 42.8 18 18.2
45-54 ., ., . . 62 26.8 14 22,6
5 5 - 6 4 ., ... ... 8 3.5 4 50.0
Over 65 . . . 0 0.0 0 0.0
Total ., ., . . . 231 100.0 47 20,3

SOURCE Report of the Committee on Chronic Kidney Disease September 1967


Table 3.— Patients Alive on Dialysis in the United States, 1970-76

Report Total number Number Number Number in Average age


dated Jan. 1 of patients alive of men of women home program In center patients Home patients
1970.. . 2,398 1,621 762 844 39 41
1971 ...,. 3,463 2,256 1,184 1,361 40 42
1 9 7 2 , . 4,981 3,212 1,751 2,001 42 43
1 9 7 3 . 7,498 4,741 2,696 2,703 44 45
1 9 7 4 10,306 6.334 3,871 3,402 44 43
1975 . . . 13,417 8,231 5,098 3,814 45 44
1976 . . 17,063 10,156 6,783 4,076 46 45

SOURCE Research Triangle Institute National Dialysis Registry, Final Report. August 1976

proximately 40 percent in 1971 and 1972, and Transplant Registry, ’ these data show a fairly
declined steadily thereafter to 24 percent in 1976 stable number of transplants being performed in
(4). (By 1979, home dialysis patients accounted the United States since 1972 (l).
for approximately 13 percent of the total dialy-
sis patient population. )
Worldwide data on kidney transplants from
the early 1950’s through May 1, 1976, are
shown in table 4. Based on the Human Renal

Table 4.— Total Kidney Transplants Worldwide by Year, 1967-76’

1953-66 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 Total
United States 1,146 462 702 872 1,139 1,676 2,232 2,417 2.218 2,399 438 15,701
Canada 93 64 83 83 126 200 165 211 177 72 – 1,274
Australia (to 4/30/75) 55 95 128 203 203 263 242 292 317 115 — 1,913
Other countries. 426 211 332 381 524 778 862 925 994 787 — 6,220
Total 1,720 832 1,245 1.539 1,992 2,917 3,501 3,845 3,706 3,373 438 25,108
a
I nc I udes al I t ransp I ants recorded u p to Ma, 1 19 ?6
Tc)Ial trdnsplanl~ 25108
Total re[ I p lents 22261
S O U R C E Amerlc dn Colleqe 01 Ptl’/\lctan~ Na! lundl Insf!tljte, ~f Healt II Orqan Trdns~)lant Rey(>tr! Mdk IVP,} L,/PIIe( 7976

Medicare coverage for ESRD treatment by contract for that Registry was terminated in
both dialysis and transplantation has been 1978, and responsibility for the ESRD Medical
available for more than 90 percent of the U.S. Information System was transferred from the
population since July 1, 1973. The number of Bureau of Quality Assurance of PHS to the
patients in the medicare ESRD program from its Medicare Bureau of the Health Care Financing
inception in 1973 through 1978 is shown in table Administration (HCFA). The new system began
5. The proportion of patients 65 years old and to issue reports in 1979.
above in the medicare ESRD patient population
has increased from 5 percent in 1974 to basically Table 5 .—Medicare ESRD Patient Population
20 percent in 1977 and 1978. 1973-78

The establishment of a data system for pro- End of calender year Total number of patients
viding accurate, consistent, and timely data on July 1, 1973a ., 11,000
1973. , . : 14$000
ESRD patients has proved to be an extremely 1974 ..., . . . . 23,000
difficult task (32). The single Medicare Registry, 1 9 7 5 . 31,000
which was to have combined both the National 1976 : , : : : ., . . 38,000
1977 44.000
Dialysis and Human Renal Transplant Regis- 1978 50,000
tries, existed briefly from 1975 through 1978 as
‘1 nce~) t Ion of proq ram
a contractor-managed system, and it issued re- SOURCE Of fire of F[nanc{dl and Acli~arlal Anal, SIS DI\ islon of Mec!(care CrJst
ports only in December 1976. The management Estimates Health Care FIndn(Incj A!mnl\trat(on March 1979
FORMAL ANALYSIS LITERATURE PERTAINING TO ESRD
In 1967, two reports were published which RTI’s initial report to the Kidney Disease Con-
constitute the primary formal analyses pertain- trol Program of PHS was prepared under a con-
ing to ESRD. One of these reports, often known tract effective June 27, “1966 (14). A subsequent
as the Gottschalk report,4 was the work of an paper set forth the methodology for conducting
expert advisory committee to BOB (31 ). The benefit-cost analysis of kidney disease (10). The
other report, known as the Burton report, 5 was full report on work performed under RTI’s con-
the work of a PHS task force which reported to tract was published later in 1968 (21). All this
the U.S. Surgeon General (17). Work on the work was either supported by or derived from
Gottschalk report was begun in mid-1966 and the Burton committee’s efforts.
completed “1 year later. The Burton report was
Several other formal analyses have also been
prepared in 4 months in 1967. The two reports
done. Pliskin, for instance, developed a health
were released together in November 1967, at a
index for the selection of chronic renal disease
press release called by PHS.
patients (27) and a methodology for projecting
A derivative literature is associated with each needed hemodialysis beds (28). Barnes pre-
report. Herbert Klarman, an economist who sented a simplified model of treating patients on
served on the Gottschalk committee, subse- chronic hospital dialysis, chronic home dialysis,
quently wrote abou: that committee’s effort in living donor transplantation, and cadaver do-
several articles (18,19,20). Similarly, Robert nor transplantation (2). Recently, Stange and
Grosse briefly discussed the Burton report to the Sumner have compared expected life-years
Surgeon General in several papers describing gained from and costs of treatment by center di-
the Health, Education, and Welfare (HEW) pro- alysis, home dialysis, and transplantation (41).
gram analyses in health done in the 1965-67
In addition, there area few other brief formal
period (1 1, 12, 13).
analyses that attempt to compare the costs and
A set of analyses on kidney disease was per- effectiveness of the several means of treatment
formed by Research Triangle Institute} (RTI). for ESRD. These add little that is new by way of
data, methodology, or results to the literature
cited above, however, and since the focus of the
present study is on the institutional factors in-
fluencing the use of formal analysis, attention is
directed mainly to the Gottschalk and Burton
reports respectively.

FORMAL ANALYSIS AND ESRD POLICY FORMULATION


In the more than 15 years during which Fed- Report to the Surgeon General (the Burton re-
eral policy toward ESRD has developed, cost port) (17). These reports stimulated further
analyses have always been central to policy for- analyses and also provided guidance to action.
mulation. But only on one occasion have other
forms of analysis been integral to the policy Report of the Committee
process. In 1966 and 1967, two efforts were
on Chronic Kidney Disease
made to apply CEA to kidney disease. The
reports that resulted have already been men- The need for a review of Federal policies and
tioned: 1) Report of the Committee on Chronic programs related to ESRD was forcefully under-
Kidney Disease to BOB (the Gottschalk report) lined for BOB by several events in 1965 and
(31), and 2) Kidney Disease Program Analysis: early 1966. First, VA submitted a budget request
to BOB for construction funds to create dialysis Federal activities in dialysis. Dr. Carl Gott-
units in a number of VA hospitals and for addi- schalk, University of North Carolina, agreed to
tional funds to staff these units. VA’s request chair the committee and helped select the mem-
prompted BOB to ask the Office of Science and bers from medicine, science, and ethics; BOB
Technology about the possibility of an external selected Klarman and Gerald Rosenthal, the
review of the VA dialysis program. That Office economists. 6 The Gottschalk committee met
agreed that such a review would be useful, but seven times from July 1966 through May 1967,
urged that it include all Federal Government ef- and submitted its report (31) to Charles
forts in ESRD. Schultze, BOB director, in September 1967; the
report was released to the public in November
The attractiveness of such a review was re-
of the same year.
inforced when NBC News, on November 28,
1965, presented a l-hour television documen- Central to any analysis is its purpose. BOB’s
tary, “Who Shall Live?” (26). Narrated by Ed- charge to the Gottschalk committee was not ful-
win Newman, that program dramatically con- ly articulated at the outset, but instead evolved
trasted the lack of funds for dying individuals over several months. Two concerns were fore-
needing dialysis treatment to the hundreds of most to BOB. One was national policy makers’
millions of dollars being spent for exploration of substantial interest at that time in realizing clin-
outer space and major weapons systems. New- ical payoff from the Nation’s large and continu-
man concluded the program by observing: ing investment in biomedical research. That in-
“What is wrong is that a medical miracle has terest was dramatized on June 27, 1966, when
been achieved and we refuse to face its implica- President Lyndon B. Johnson called the Director
tions. We continue to argue over where the of the National Institutes of Health (NIH) and
money is coming from—and we have the mon- the directors of the individual institutes of NIH
ey. ” Representative Melvin Laird (R., Wis. ), to the White House to ask pointedly about the
then ranking Republican member of the House practical benefits the Nation was receiving from
appropriations subcommittee for HEW, was NIH-supported biomedical research (42).
quoted: “We’re spending billions of dollars to
BOB’s second concern was to involve itself
get to the moon, and it seems to me that these
early in decisionmaking about new medical pro-
human problems, which we have right here on
grams, especially those having major resource
earth, need to be solved. ” BOB, the Office of
implications, so that policies could be shaped
Science and Technology, and the White House
from a national perspective. Within BOB, Irv-
all recognized that public pressures for more
ing Lewis, Chief of the Health and Welfare Divi-
Federal funding of dialysis were building.
sion, recalls: “We were very troubled by the VA
The expansion of dialysis-related activities request. There was a VA program, there was a
was being actively promoted within PHS. Dr. PHS program, but there was no national ap-
James Kimmey, chief of PHS’s Renal Disease proach to the problem” (22). The advisory com-
Activity Branch, Division of Chronic Diseases, mittee of experts was convened to help BOB
supported by certain congressional and medical develop a national approach to ESRD.
allies, was advocating a dialysis program that
h l e m b t ’ r e n l n l l t t{e t hat f~~)fl (lr~anlzt’li n t’rt’ I )r lit!
would grow to an eventual level of $150 million
nard Anl(~>. I>u At’ l] n I t’(’r~l t \ I ~r I t’t~ I \ ~\’ 131 u(’m It ~ \ n Ii’ t’ r~l t \ ~~t
annually. In March 1966, however, BOB staff l’t’nn~t’lvanl~ I)r \~’lllitlnl A [;rt’~’nt’ ( rll~~’r>it \ t~t 1<(~( ht’>tt’r
discovered that Kimmey’s plan had not consid- ])r [ {t,rbt,rt Kldrman l,)hn~ l+t)pkln~ IInlt(rs[t \ 1 )r l(Ihn > ~’]
I<jr]<jn lln]i,t,r~]t~ t)t (- .Illt{)rnla S.]n [.r.inc IW {) [)r (;t,rald l<ow,n-
ered either the VA program or the offsetting ef-
t h a t l}rclndt’]~ L lnltt’r~ll \ t)w a r hl I<ut’bhauwn 1~(’1’i’~’1~~’
fects of providing transplants to some patients, l’llmpt(~n, Ly(}ns, and Ca tes, New York, Dr C,e[~rge E. Sch rel ner
although it did acknowledge that some dialysis G(Jrgetown Unl\’ers]ty, and I>r. D(~naId W’ Selciin Unr\ft>rsitv (lt
Texa\, Dallas. The advl~(~rs to the c(>mmlt tee were Dr Robert \\’
patients would die (24). The need for a Govern-
Berllner, Natl(~nal Heart In\t]tutt’ [>r B e r n a r d Greenberg Unl\fer-
ment-wide review seemed increasingly clear. \I t ~’ (}I Nor-t h C-a rol ln~ a n d D r Arnold S Nash, Llnr ~’er~l t y (lt
N’orth C~r(~llna T h e BOEl pr(lte>~l(~nal ~upp(~rtlng t h e c(lmmlttt’c’
In early 1966, therefore, BOB organized an wa~ Plerrc S [’almtr h e rcp(~rted to I r v i n g I l.ew’1~ Ch]et (~f
advisory committee of outside experts to review IKIU s Ht’alt h ancj \3’elf art, [l(t’l+i(~n
BOB expressed its two primary concerns at fraction of the GNP), ” treatment for ESRD
the Gottschalk committee’s initial meeting in should be made universally available (31):
July 1966, but clear definition of the committee’s
The reasons for this decision are the irrever-
mission came later. The committee’s October sibilit y of the decision not to do so, as far as an
meeting involved conversations with visitin g individual is concerned; the existence for the
foreign physicians attending the International first time of a technology capable of prolonging
Congress on Nephrology. In November, the the lives of persons otherwise doomed to an
group visited Dr. Belding H. Scribner, a pioneer early death; the relative youth of these persons;
in treating kidney failure by hemodialysis, in the prospects of further improvements in tech-
Seattle to learn about home dialysis and talk to nology; and the fact that patients are known and
patients. Not until the December meeting, how- identifiable, not members of a statistical distri-
ever, did BOB’s charge to the committee come bution, enhances the community’s interest in
into sharp focus. doing somethin g in their behalf.
The committee’s CEA took as it point of
Some on the committee wished to conduct a
departure the committee’s conclusion and
CBA addressing the relative priorit y “of in-
recommendation that treatment be provided to
vesting resources in treatment of chronic kidney
all in medical need of it.
disease as against other needs in the health field”
(37). One suggestion was to convene a group of The Gottschalk report also dealt with the
health generalists to consider alternative claims issue of prevention versus treatment. In trans-
on resources. A majority of those on the com- mitting the report to BOB Director Schultze,
mittee, however, held that determination of Gottschalk wrote (31):
priorities rested with the Surgeon General, the
Secretary of HEW, the BOB Director, and the Prevention is obviously preferable to treat-
ment of disease. Unfortunately, knowledge con-
President. Irving Lewis, respondin g to an in-
cerning the causes and prevention of end-stage
quiry from his BOB staff, concurred: “I think kidney disease is limited and this is an area in
this is right. They should, however, give prior- which an expanded research effort is required.
ities within kidney disease.”7 Furthermore, even if a completely successful
method of prevention is developed it will have
The Gottschalk committee’s report, conse-
no significant impact on the numbers of people
quently, focused on those individuals with dying from end-stage kidney disease for many
chronic kidney failure who required treatment years. Therefore, the Committee recommends a
by hemodialysis or kidney transplantation (31). national treatment program aimed at providing
These two forms of treatment, it said, “are now chronic dialysis and/or transplantation for all of
available as fruits of research and development the American population for whom it is medical-
programs and are life-saving.” Though by no ly indicated.
means optimal, these treatments could add a The conclusions of the committee’s report
significant number of years to the lives of in- were the following: 1) the high cost of ESRD
dividuals “now dying because these treatment treatment required Federal financial assistance;8
forms are not generally available. ” The cost- 2) ESRD treatment should be universally avail-
effectiveness section of the Gottschalk report
able, not arbitrarily provided, say, to veterans,
elaborated the reasons for not doing CBA, or but denied to nonveterans; and 3) the Federal
weighing the funds used for treating chronic
commitment to ESRD treatment necessarily had
kidney failure against alternative uses of re- to be a continuing one. The Gottschalk commit-
sources. The basic problem with CBA, it noted, tee also concluded that continuing medical re-
was placing a value on human life. Further- search into the causes of kidney disease and
more, the report said, “in the absence of over-
whelming costs (as reflected by an appreciable
‘This conclusion was based on written and oral testim{~ny re-
ceived by the committee tr(~m LOUIS Reed, %clal Security Admln-
‘Klarman recalls that he and R(wenthal spent much time in 1967 istra tion, and from representatives of all major health insurance
attempting, wlth(~ut success, t[~ prepare a CBA, plans.
means of prevention was needed, though it did year. ’ Costs for 16 center dialysis programs
not consider this issue at any length. ranged from $10,000 to $21,000 per patient per
year. Five home dialysis programs had costs
The recommendations that followed from
ranging from $3,750 to $9,800 per year.
these conclusions dealt with the supply of and
demand for ESRD treatment, and the manage- The section on transplantation outlined a
ment of Federal efforts in this area. On the sup- strong case for that treatment relative to dial-
ply side, the Gottschalk committee recom- ysis. The report noted an important shift over
mended Federal investment in establishing com- time in organ donor source—from identical
prehensive kidney centers and satellite com- twins to close blood relatives to nonliving (ca-
munity dialysis units, as well as in training daver) donors. Cadaver organs, it said, were be-
health professionals to staff such facilities. On coming the most important source of organs,
the demand side, its recommendation was to owing in part to high success rates with them.
provide for patient care financing by amending
Worldwide mortality data from the Human
title XVIII (medicare) of the Social Security Act.
Renal Transplant Registry, however, showed
Specifically, the committee recommended enact- that survival rates declined with the shift from
ing the Johnson administration’s p e n d i n g
identical twins to siblings to parents to un-
amendment to extend medicare coverage to the related living donors to cadavers (25). The best
disabled under 65 years of age and redefining
l-year survival rate for cadaver kidneys was 38
disabled to include those with kidney failure
percent. The report concluded that these world-
even though they might continue to work as a wide data were of little predictive value, how-
result of treatment. On Federal management, it
ever, since they included the early experimental
suggested “an appropriate mechanism” for coor-
stage of transplantation. The report used only
dinating governmental efforts. data for the 2 most recent years, broken down
The formal analysis in the committee’s report by large and small transplantation centers.
included sections on treatment by hemodialysis These data showed l-year kidney survival rates
and by transplantation, a discussion of the in- of 65 percent for sibling donors and 39 percent
cidence and prevalence of chronic kidney fail- for cadavers transplanted in large centers, re-
ure, a projection of treatment needs, and CEA sults deemed “noteworthy” and “very encour-
itself (31). The hemodialysis section addressed aging. ”
patient selection criteria. Ideal candidates for The committee’s optimism about the future of
hemodialysis were then thought to be persons renal transplantation was based on two subsets
between 15 and 45 years of age, the upper age of data from the Human Renal Transplant Reg-
limit was expected to rise, however, and for istry. The first excluded all deaths save those re-
analytical purposes, the committee used a 54- sulting from uncontrollable rejection: 3-year
year upper age limit. Vascular diseases as med- survival rates for siblings and parents were 70
ical conditions limiting treatment were briefly percent and over 60 percent for cadavers. The
discussed, as were the limits of dialyzing second set included deaths from rejection and
children. It was also noted that the degree of infection: l-year survival rates were 66 percent
rehabilitation of dialysis patients varied widely; from close relatives and 54 percent from cadav-
existing data were of little use on the matter. It er kidneys. The committee’s report found it “im-
was expected that psychosocial problems of pa- pressive” that projections for fifth year survival
tients adapting to dialysis would increase as for all cadaver kidneys, “if technical failures and
selection criteria were relaxed. deaths due to causes other than infection or re-
PHS and VA data were analyzed for some in- jection are excluded, ” were 40 percent. The fu-
dication of mortality. Later in the analysis, pro-
jections would be based on 15-percent mortality
by Bernard Greenberg.
of a dialysis population cohort in its first year, detailed survivorship
and a 10-percent mortality in each successive
10 . Background Paper #2: Case Studies of Medical Technologies

ture prospects for transplantation, the report Reported costs for transplantation from four
suggested, were the following (31): centers ranged from $10,000 to $22,000, in-
cluding preoperative and postoperative dialysis
From the subsets it is possible to extrapolate
costs. One center reported an average cost of
what might be expected from continuing experi-
ence and excellent management with existing $13,300 for its 46 most recent transplants, and
methods of treatment, i.e., between 65 percent the Gottschalk committee judged that as the
and 75 percent l-year survival for a closely “most valid estimate. ”10
related donor, between 40 percent and 50 per- The report contained a long section on inci-
cent survival for a cadaver donor. Additional
dence and prevalence of chronic kidney failure.
known factors expected to improve the results
further are (a) selection of antigenically compati- Noting the absence of any periodic reporting on
ble donors, (b) improved immunosuppression, this disease, the Gottschalk committee devel-
and (c) the induction of specific immunologic oped two estimates of the potential dialysis
tolerance. cases for 1964, and from these derived an upper
limit, lower limit, and most probable annual di-
Several features about these projections for
alysis caseload. Mortality estimates were de-
kidney survival deserve mention. First, no esti-
rived from actual data on dialysis: 15 percent
mates of the magnitude of the shift from living
mortality in the first year; 10 percent for each
to cadaver donors were given in its report; nor
successive year. The kidney transplant failure
were different projections developed for differ-
rate was estimated to be 50 percent annually for
ent degrees of shift. Second, the two subsets of
the first 2 years and 5 percent each year there-
Registry data on which the projections were
after. Projections of the dialysis caseload for the
based were not published. Finally, it was never
decade from 1968 through 1977 were made on
clearly indicated how the assumptions based on
the basis of varying levels of chronic kidney fail-
these data subsets were used in the later CEA.
ure and varying numbers of patients trans-
These matters are important because the op- planted. These projections are shown in table 6.
timism about transplantation, based on expert If one compares the 1977 dialysis caseload for
testimony heard by the committee, was never maximum level of transplantation and lowest
fully realized. One-year survival for cadaver level of total cases (29,201) with that for no
transplants subsequently reached 55 percent in transplantation and the maximum number of di-
1970 and then declined slightly (1,43). At the alysis cases (53,633), it is obvious that projec-
time of the committee’s report, there were few IOKlarman developed this estimate durin g a visit to Dr. David
who questioned the assumption that success Hume, one of the kidney transplant pioneers, at the Medical Col-
with transplantation would improve with time. lege of Virginia in Richmond.

Table 6.—Predicted Caseload in Patient Years of Dialysis Under Varying Levels of Expected Cases
of Chronic Uremia and Differing Amounts of Transplantation, 1968-77

Probable number Maximum number
No transplantation, and of transplantations, and of transplantations, and
number of cases is: number of cases is: number of cases is:
Most Most Most
Year Lower probable Upper Lower probable Upper —Lower probable Upper
1968 . . . . . . 5,530 6,436 7,541 – 5 , 3 5 4 6,261 7,365 5,333 6,239 7,344
1969 . . . . . . 10,470 12,187 14,279 9,982 11,698 13,790 9,914 11,636 13,722
1970 . . . . . . 15,038 17,503 20,506 14,158 16,624 19,626 14,037 16,503 19,506
1971 . . . . . . 19,265 22,423 26,269 17,914 21,071 24,917 17,588 20,747 24,592
1972 . . . . . . 23,191 26,994 31,624 21,293 25,096 29,727 20,584 24,387 29,017
1973 ....., 26,847 31,252 36,611 24,325 28,728 34,088 23,141 27,544 32,905
1974, . . . . . 30,265 35,229 41,272 27,016 31,979 38,021 25,300 30,263 36,305
1975 . . . . . . 33,468 38,956 45,638 29,367 34,856 41,538 27,043 32,532 39,213
1976 . . . . . . 36,482 42,463 49,747 31,382 37,363 44,648 28,354 34,334 41,620
1977 ..., 39,332 45,779 53,633 33,053 39,498 47,351 29,201 35,649 43,505
— — — . . — — - — — — .
SOURCE Report O( the Corrrrrr/ffee on Chronic Kfdney Dsease, September 1967
tions vary substantially as a consequence of times better) than an additional life-year from
their underlying assumptions. Such wide varia- dialysis.
tion can obviously affect planning for facilities,
The conclusions of the Gottschalk report’s
if program decisions are to be based on the pro-
CEA, not surprisingly, were these: 1) The max-
jections.
imum transplantation course was a better way
The heart of the Gottschalk report’s CEA was to increase life expectancy for a given cost; 2)
a comparison of the expected life-years added the value of a home dialysis program did not
by transplantation and by dialysis with the differ much from that of transplantation, em-
predicted costs of each. The critical assumptions phasizing the proportion of transplantation
for transplantation were the 50-percent kidney costs attributable to dialysis; and 3) any shift in
survival at the end of 2 years and a 5-percent the dialysis population away from center dialy-
annual failure rate thereafter. On the basis of sis and toward home dialysis offered substantial
these assumptions, transplantation led to an ex- economic gain.
pected 17 additional life years (13.3 from trans-
The committee’s recommendation, therefore,
plantation and 3.9 from dialysis before and after
was for a national treatment program aimed at
a transplantation). Dialysis, on the other hand,
building adequate treatment capacity and pay-
based on a 15-percent first year mortality and
ing patient bills. Within that policy, the com-
lo-percent for each successive year, led to an ex-
mittee said, transplantation should be encour-
pected 9 additional life-years.
aged to the maximum extent possible, and home
The present value costs of 17 years of addi- dialysis should be encouraged over center
tional life from transplantation were calculated dialysis,
to be $44,500. The comparable present value
The estimated total costs, including both Fed-
costs of 9 additional life-years from dialysis
eral and non-Federal funds, for the patient care
were calculated to be $104,000 for center dialy-
portion of the national dialysis and trans-
sis and $38,000 for home dialysis; if there were a
plantation program recommended by the Gott-
50-50 split between the two, the average esti-
schalk committee were $40 million (low) and
mated cost for dialysis would be $71,000. (The
$49 million (probable) for fiscal 1970, the first
present value estimates were based on 4- and 5-
year, and $157 million (low) and $205 million
percent discount rates, respectively, for center
(probable) for fiscal 1974, the fifth year. The
and home dialysis. )
committee’s table summarizing the cost esti-
The results of the comparison are presented in mates is reproduced as table 8. Estimates for
table 7. An adjustment for quality of life was total patients treated by both dialysis and
made for transplantation based on the observa- transplantation were 3,662 in the first year and
tion that an additional year of life from a suc- 18,500 in the fifth. The estimated costs to the
cessful transplantation is much better (1.25 Federal Government, from fiscal years 1969
through 1975, for construction or renovation,
initial equipment, operating subsidy, and train-
Table 7.— Increased Life-Years and Costs per ing personnel for kidney centers and community
Additional Life-Year by Means of Treatment dialysis units, respectively, were $29 million,
$22 million, $30 million, $30 million, $22 mil-
Life-years cost
Modality cost gained per year
lion, $23 million, and $15 million.
Dialysis
Center. . . . . . $104,000 9 $11,600 Kidney Disease Program Analysis:
Home. ... . . . 38,000 9 4,200
Average. . . . 71,000 9 7,900
A Report to the Surgeon General
Transplantation
Unadjusted. . . . . . 44,500 17 2,600
In the early 1960’s, under Defense Secretary
Adjusted for quality. 44,500 20.5 2,200 Robert McNamara, CEA was introduced into
— national security decisionmaking with a flour-
S O U R C E Report 01 fhe Commlltee on Chronic Kldr7ey f)(sease September
1967 ish. In 1965, Henry S. Rowen left his position as
In-center dialysis Home dialysis Transplantations Total program
Cost/ - ‘Estimated Cost/ Estimated Cost/ Estimated Estimated
Patients patient Cost a Patients patient cost a Patients trans- Costa Patients cost a
Fiscal year treated year ( $ 0 0 0., 0 0 0 ) treated
— ‘ year ($000,000) treated plant ($000,000)l treated ($000,000).
1970
Low estimate 1,456 $10,000 $15 1,456 $4,000 $17 750 $10,000 $ 8 3,662 $40
Probable . . . 1,456 “14,000 20 1,456 5,000 19 750 13,000 10 3,662 49
1971
Low estimate 2,194 “ 0,000 22 2,194 4,000 16 1,250 10,000 13 5,638 51
Probable . . 2,194 14,000 31 2,194 5,000 18 1,250 13,000 16 5,638 65
1972
Low estimate 3,731 10,000 37 3,731 4,000 30 1,750 10,000 18 9,212 85
Probable 3,731 14,000 52 3,731 5.000 34 1,750 13,000 23 9,212 109
7973
Low estimate 5,878 10,000 59 5,879 4,000 45 2,550 10,000 26 4,307 130
Probable 5,878 4,000 82 5,879 5,000 51 2,550 3,000 33 4,307 166
1974
Low estimate 7,575 0,000 76 7,576 4,000 47 3.350 0,000 34 18,501 157
Probable 7,575 4,000 106 7,576 5,000 55 3,350 3,000 44 18,501 205
1975
Low estimate 8,925 0,000 89 8,926 4,000 49 4,150 0,000 42 22,001 180
Probable 8,925 4,000 125 8,926 5,000 58 4,150 3,000 54 22,001 237
aRounded to nearest m(lllon
bBa~ed on ~pp c ~ables do ~n(j 41 Ex,:lu[je5 ~atlent ~edr5 of dla IySl~ rleeded for [ransplanfs (table d 1 I because the COSt of th(s dtalysls IS Included In the cost per traOS
plantation For 197375 the numl)er of pal,enl years o! dlalysls for new cases orglnatlng (n these years have been deducted because they are capability rather than re
qulrements they have beer replaced by mo>l probable number of new pal (ents need)ng d(alys{s (table 40) translated to patlenl years by using 925 percent the first
year 872 percenl second y~ar dn(i 876 percent thlr(j y ear
cFrom table 3
dlncludes ,n[tlal home dlalys(s e(lulpn)ent dnd Ira(n(ng costs of $lIJ 000 for new pat(~nts on home d(alys(s 1970 $,11 ‘2 rn!(l(on
1971 $74 mllllon 1972 $154 fnltllorl
1973 $21 5 mill ton 1974$17 ml Ijon 1975 $135 m[ll Ion Assumes that equ lpment provided for home d(alyws patients who have d(ed or been transplanted WIII be
made aval I able for new pat Ients :,larl I ng on home d{aly S(S
SOURCE Reporl of ffie Cornrn/(/e? on Ctrrorr/c K/drrev D/sease September 1977

Deputy Assistant Secretary of Defense for Sys- facilities, kidney disease, manpower, and nar-
tems Analysis to become the Assistant Director cotic addiction. 11 For each issue, these groups
of BOB. In that position, aided by a formal dec- were to discuss: 1) goals and objectives and
laration from President Lyndon B. Johnson, he ways of measuring them; 2) alternative a p -
promoted the use of CBA and CEA throughout proaches to the same objectives; 3) the cost “of
the domestic agencies of the Federal Govern- reaching various points on the continuum of ob-
ment. Also in 1965, John Gardner became the jectives by means of alternative approaches;”
Secretary of HEW and took a number of steps to and 4) assumptions underlying conclusions, the
increase his control over the far-flung HEW uncertainties affecting the estimates, and the
bureaucracy. One step was to create the posi- issues not resolvable at that time. Each alter-
tion of Assistant Secretary for Planning and native approach was to consider “the relative
Evaluation to do for HEW what the systems mix of research, prevention, and control. ” The
analysts had done for the Defense Department. program analysis groups were to complete their
The first occupant of that post, William work by May 30, 1967, and the resulting reports
Gorham, came from the Pentagon. Early in were to guide the development of the HEW’s
1966, Gorham and his staff sought to promote 1969-1973 5-year program and financial plan, as
the use of CEA and CBA in HEW (34). well as the fiscal 1969 budget and legislative
proposals (9).
In response to these developments at HEW,
the U.S. Surgeon General, William H. Stewart,
in March 1967 established health program anal- ‘ A l~be l)r~~~r,]m Nlemt)rdndum ~)n St’!c’c ted I)Iwase ~ontro]”
l’r(lgrdm~, drafted I }rt’c~r c’c]rllc’r, w<i~ c I ted ds dn cxcrc iw t () gal n
ysis groups to address disease control issues t’xpc>r]enc e I n ~ppl yi ng t] n.] I y’ t ]ca 1 met h(d~ t () t hl~ \t ULIII L)} d lwaw
related to air pollution, cancer, health care con t rol progrc] ms.
The kidney disease program analysis group, The Burton group’s analysis was based on a
chaired by Dr. Benjamin T. Burton, was com- breakdown of kidney disease into four primary
posed of individuals from various parts of types:
PHS. 12 Its charge from the Surgeon General was
1. infectious diseases,
a general one given to all the program groups.
2. hypersensitivity diseases,
The kidney disease group, therefore, translated
3. diseases associated with hypertension,
this general guidance into a charge to perform
and
“a logical analysis of programs leading to a
4. end-stage disease.
solution or amelioration of the problem of kid-
ney disease” (17). The group identified tradi- The progression of each of the first three types
tional disease control mechanisms for such a was to the same functional equivalent—end-
task as prevention, diagnostic and therapeutic stage—where irreversible deterioration of kid-
techniques, laboratory and clinical research, ney function had proceeded so far that un-
manpower training, public education, and the treated individuals would die.
construction of specialized facilities. It made the
Each of the four types of kidney disease was
assumption that no “single program component
analyzed in terms of four hypothetical pro-
would lead to a major reduction in the national
grams, delineated by time, funding level, and
kidney disease problem, ” so a mix of ap-
state of clinical practice. The four different pro-
proaches would have to be employed. It further
grams were described as follows (17):13
assumed that “unlimited Federal funds” were
not available for any given disease problem, 1. hypothetical program at the current HEW
such as kidney disease; therefore, “a rational expenditure level (essentially $47 million),
balance” had to be struck between various ap- based on the current state of the art;
proaches “to derive maximum benefits from any 2. hypothetical program at an intermediate
current or possibly extended future Federal ef- HEW expenditure level (roughly 21/2 times
forts. ” These controlling assumptions affected the current level), based on the current
the definition of the problem for analysis, the state of the art;
analysis itself, and the implications of the 3. hypothetical program at an accelerated
analysis. HEW expenditure level (roughly six times
the current level), based on the current
The Burton report to the Surgeon General
state of the art; and
(17) was organized into six chapters: the sum-
4. hypothetical program for fiscal year 1975,
mary of the report and chapters dealing suc-
at “an accelerated HEW expenditure level
cessively with the major types of kidney disease;
(roughly six times the current level), based
current kidney disease control programs, both
on the expected advanced state of the art
Federal and non-Federal; research methods; the
in 1975.
program analysis; and the cost of treating all pa-
tients with chronic kidney failure. Within each of the resulting 16 analyses, atten-
tion was given to “a rational mix of program
components” —prevention, diagnosis and treat-
ment, research, training, and facilities. The
fourth program, it should be noted, was based
on numerous assumptions about scientific and
clinical progress by 1975; it is highly sensitive to
those assumptions and consequently its projec-
tions are not discussed below.

‘ ‘Freemdn recd]]~ that the intermediate’ prqectlons were c]ose


to redl number~ and the ‘ decelerated p r o j e c t l(~ns were t(~tdl]v
ILkd]L?eLi
14 . Background Paper #2: Case Studies of Medical Technologies

The estimated annual costs to HEW are lion, and $813 million. (All cost figures are in
shown in table 9 below. The totals for each of constant 1966 dollars. )
the four resource levels, respectively, are $47
million, $117 million, $290 million, and $293 Short- and long-term benefits from these vari-
million. The corresponding total annual nation- ous expenditure levels were estimated. Short-
al costs including HEW costs (not shown in the term benefits were calculated for reductions in
table) are $241 million, $333 million, $526 mil- annual mortality, number of new cases, and

Table 9 .— HEW Cost Summary (in thousands of dollars)

Program level
— Infectious Hypersensitivity Hypertensive End-stage cost Percent
Current expenditure Ievelb
Diagnosis, prevention, treatment:
Prevent ion (including education
and administration) . . . . . . . . . . . $3,803 $1,500 $4,000 — $9,303 19.920/.
Diagnosis and treatment. . . . . . . . . — — — $7,240 7,240 15.50
days of morbidity. Long-term benefits were reduction of deaths from ESRD. Third, only the
calculated in terms of eventual annual reduction direct treatment of ESRD offered the best pro-
in number of cases reaching ESRD. Long-term, spect for reducing deaths from that type of
though never specified, is essentially the 20th kidney disease. Although the Burton report
year of program effort. For ESRD, only short- itself nowhere reaches these conclusions in so
term mortality reduction is shown, since that is crisp a fashion, careful perusal of table 10 pro-
all that is possible. The calculated benefits are vides the basis for these inferences.
shown in table 10.
Actually, the Burton report itself gives an im-
What conclusions are to be drawn from the pression somewhat at variance with the afore-
Burton study? First, additional resources in mentioned conclusions. Figure 3 of the report,
prevention beyond current levels promised little reproduced as figure 1, discusses the changing
additional benefit in reduced deaths and rather “state of the art” due to advances from scientific
modest additional benefits in reduced preva- research. The clear implication is that better
lence and morbidity. Second, the prevention of knowledge about preventing and treating pri-
hypertension offered an important means for mary kidney disease would cut deeply into the

Table 10.—Program Benefits

Benefits by kidney disease


— category —
Program level — Infectious Hypersensitivity Hypertensive End-stage Total
Current expenditure /eve/b
Short-term benefit-reductions
Mortality. ., . . . . . . . . . . . . . . 70 deaths 610 deaths 2,190 deaths 690 deaths 3,560 deaths
Prevalence . . . . . . . . . . . . . 3,231,260 cases 27,000 cases 3,258,260 cases
Morbid days . . . . . . . . . . . . . . 15,962,420 days 1,802,000 days 17,764,420 days
Long-term benefit-reductions
Annual . . . . . . . . . . . . . . . . . . 1,750 deaths 4,330 deaths 6,080 deaths
Cumulative. . . . . . . . . . . . . . 25,850 deaths 86,560 deaths 112,410 deaths
Intermediate expenditure levelb
Short-term benefit-reductions
Mortality. . . . . . . . . . . . . . . . 70 deaths 610 deaths 2,270 deaths 1,560 deaths 4,510 deaths
Prevalence ... ... . . . . . . . 3,243,860 cases 39,880 cases — 3,278.740 cases
Morbid days. . . . . . . . . . . . . . 16,273,640 days 2,056,820 days 18,330,460 days
Long-term benefit-reductions
Annual . . . . . . . . . . . . . . . . 1,770 deaths 4,820 deaths 6,590 deaths
Cumulative. . . . . . . . . . . . . . . 26,190 deaths 96,300 deaths 122,490 deaths
Accelerated expenditure levelb
Short-term benefit-reductions
Mortality. ., . . . . . . . . . 70 deaths 610 deaths 2,380 deaths 7,675 deaths 10,735 deaths
Prevalence . . . . . . . . ... 3,292,860 cases 42,750 cases — 3.335,610 cases
Morbid days . . . . . . . . . . . . 17,483,880 days 2,311,340 days 19,795,220 days
Long-term benefit-reductions
Annual . . . . . . . . . . . . . . . . . . 1,870 deaths 4,820 deaths 6,690 deaths
Cumulative. . . . . . . . . . . . . . . 27,480 deaths 96,300 deaths 123,780 deaths
Accelerated expenditure levelc
Short-term benefit-reductions
Mortality. . . . . . . . . . . . . . . . . 80 deaths 770 deaths 9,300 deaths 27,399 deaths 37,549 deaths
Prevalence . . . . . . . . . 5,630,720 cases 62.250 cases 289.690 cases 5,991,723 cases
Morbid days . . . . . . . . . . . . . . 26,064,430 days 2,610,000 days 5,578,860 days 34,253,290 days
Long-term benefit-reductions
Annual . . . . . . . . . 4,125 deaths 8,610 deaths 9,480 deaths 21,090 deaths
Cumulative. . . . . . . . . . . 76,500 deaths 320,000 deaths 189,660 deaths 586,160 deaths
.
Short term benefits – reduction In annual mortal~ty, etc when piograrn-ls fully op-e-ra~lve
Long term annual benefits—evenlual annual reduction [n number of cases reachtng end stage kidney disease
Long-term cumulative benef!ts– sum total of long term annual benefits
aRenal disease associated wrth hwertens(on
bcurrenl state of the art
cAdvanced state of the art
SOURCE Kfdrrey D/sease Program Analysls A Reporf 10 the Surgeon General (Washington D C DHEW JLIIY 19671
Treat men
end-stage
kidney
disease

I I Dialysis .

Prevention
and
treatment of
primary
kidney
diseases

SOURCE. Program A Surgeon Genera/ (Washington D C DHEW July 1967)

need to treat ESRD. That this development has


scientific advance in analyzin g the costs and
not come to pass by 1980 (as the Gottschalk re- benefits of medical care.
port’s optimism about transplantation has also
failed to materialize) should be a reminder to all
The final chapter of the Burton report dealt
about the dangers of relying on “inevitable”
with the cost of treating all patients threatened
by end-stage kidney failure, either by dialysis or Based on first and successive year cohorts of
transplantation. Though this issue was not part 40,000 patients, the projected costs were:
of the original charge to the group, the report
1st year $611 million 40,000 patients
argued, it was a logical corollary of the previous 5th year $1,044 million 102,000 patients
analysis. The policy question was stated in the 15th year $2,702 million 179,000 patients
report in the following way (17):
Having laid out a program for treating all
In any consideration of possible programs for those vulnerable to kidney failure and having
the amelioration of the kidney disease problem, developed the corresponding cost estimates, the
the overall expense of treating all patients Burton report then limited the domain of appli-
threatened with a uremic death regardless of the cability of its analysis. It noted that “supply”
possible costs, for humanitarian reasons, repre- constraints of trained personnel and facilities
sents one extreme in a broad spectrum of possi-
would limit the rate of program buildup. More
ble programs. It should therefore be ascertained
to serve as a maximal benchmark for any inten- significantly, it reduced the “demand” substan-
sive attempt at program analysis or planning. tially from 40,000 vulnerable to an annual
cohort of 8,000 to 10,000 individuals ideally
Unlike the Gottschalk committee, which took suited for dialysis and transplantation.
treatment as its point of origin, the Burton com-
mittee took it as one extreme in the range of Finally, on the penultimate page of the Burton
possible programs. committee’s report to the Surgeon General, it
was noted that (17):
The Burton committee assumed that 50,000
patients were vulnerable to ESRD year after With this general framework in mind and
year, of whom 10,000 could be treated by “con- utilizing the elements and computations in Sec-
servative management” (primarily dietary con- tion V of Chapter 5, it is possible to arrive at
t ro l). Of the remainin g patients, 11,000 were practical and feasible predictions concerning the
cost of such a program and the overall number
candidates for transplantation, 2,000 ideal can- of patients that could be accommodated by i t
didates, and another 9,000 satisfactory. The during each of the first few years, the number of
assumption was made, therefore, that 29,000 patients who are likely to- graduate from this
new patients were available for and would be program permanently each year because of suc-
placed on dialysis each year. cessful transplantation, the number of individ-
uals who would have to be maintained perma-
Estimated annual outcomes for transplanta- nently with the aid of chronic dialysis, and the
tion among the ideal candidates were that 80 number of new patients which such a program
percent would be “cured,” 10 percent would fail could accommodate each year.
and be placed on dialysis, and 10 percent would
die; the corresponding values for satisfactory Having calculated costs for the much less likely
candidates were 30, 30, and 40. For the dialysis 40,000-patient annual cohort, however, the re-
patients, it was estimated that 50 percent would port stopped abruptly without making any cal-
die in the first year, and there would be a 90- culations for the smaller, more probable, 8,000 -
percent survival rate for those remaining in each to 1(),000-patient cohort!
successive year. Overall, the Burton committee report had a
number of problems, some of which were stylis-
Costs for the first 15 years of the program
tic. First, there was a somewhat naive belief in
were estimated by the Burton committee using
“present cost” figures of $16,000 for a transplant “decisions based upon a thorough, dispassion-
operation and $15,000 per year for dialysis ate, and logical analysis” and in the possibility
of allocating resources “on the basis of logical
treatment. (No home dialysis was projected. )
priorities. ” Second, the 16 different scenarios
.. make the analysis entirely too complex to be of
]
‘A tuture c (wt’ pr<)]cc tl~~n, U+ I ng $12,000 t ( ~r eac h t ra n~pla n t
and !3 10,000 tor d ld ] y~l \ p~’r ~rea r wa~ a I S( ) m~de, on the a i~u m p-
much use by policy makers. Third, each scenario
t I{ln that c ott~ WIC)U Id dcc 1 I nt, ot,er t I mt~ t t-()117 I nc r(,d ~td et t )( It,nc I(,\ is highly complex in its own right, built upon
I n prov Id I ng treat men t numerous assumptions about the clinical feasi-
bility of the various components or forms of in- Secretary for Health, and the Assistant Secre-
tervention, the appropriate “mix” of compo- tary for Planning and Evaluation which might
nents, and the relative shares of Federal and have sharpened the focus of the committee’s
non-Federal funds. Fourth, the narrative tends study.
toward a repetitious presentation of calculations
The two committees differed in composition.
based on certain assumptions, justified by rela-
The Gottschalk committee’s members and con-
tively little description of clinical feasibility, and
sultants included three renal physiologists, two
often supported only by citations to “best esti-
nephrologists, an immunologist, a transplant
mate” or “informed medical judgment .“
surgeon, a psychiatrist, two economists, a law-
yer, a biostatistian, and a professor of ethics.
The Policy and Bureaucratic Contexts These people came primarily from universities,
The Gottschalk and Burton committees and especially academic medicine, but also from
worked at approximately the same time; they Government and the private practice of law.
addressed similar subject matter; and their re- The Burton committee’s members and consult-
ports were issued simultaneously. It is worth- ants included one nephrologist, the director of
while to compare and contrast the two commit- the National Institute of Arthritis and Metabolic
tees, and their respective reports, and the policy Diseases’ (NIAMD) artificial kidney program,
and bureaucratic contexts in which they oper- the director of the National Institute of Allergy
ated. and Infectious Diseases’ transplant immunology
program, two professionals from the PHS kid-
The two committees differed in their initial
ney disease control program, several other PHS
stimulus and central purpose. The Gottschalk
officials, and three operations analysts. Mem-
committee was a direct response to the existence
bers were drawn exclusively from the Govern-
of expensive, lifesaving therapies developed
ment, consultants from a nonprofit research
largely from publicly financed medical research
firm, Scientific and clinical competence was
and to the mounting pressures to make those
greater on the Gottschalk committee.
treatments available to the general public. That
committee was not asked to address the ques- The duration of the two committees differed
tion of whether treatment for ESRD should be substantially. The Gottschalk committee met
provided relative to alternative uses of re- first in mid-1966 and a total of seven times over
sources; it was asked how such treatment the next year. A draft report was circulated for
should be made available if the basic policy comment in the summer of 1967 and a final re-
choice was to go forward. port was presented to the Director of BOB that
September. The Burton committee met initially
The Burton committee arose from the general
in late March 1967. Its final report was trans-
effort within HEW to use program budgeting,
mitted to the Surgeon General in late July, only
systems analysis, and CBA for allocating re-
4 months later.
sources to major programs. In general, the com-
missioned studies were undertaken in order to In substantive terms, the reports generally
provide guidance for HEW’s 5-year program agreed about the value of research, differed
and financial plan and for fiscal year 1969 budg- somewhat on the value of prevention, and dif-
et and legislative proposals. An attachment to a fered greatly on the treatment of ESRD. The
memorandum from Secretary Gardner stated, Gottschalk committee concluded that “continu-
“Of particular importance this year is the ques- ing and expanded research in the fields of trans-
tion of kidney diseases. The future of Federal plantation immunity, organ procurement and
support for hemodialysis, transplantation, and storage, and dialysis is essential for optimal de-
prevention needs decisions based on thorough velopment of these methods of treatment” (31).
analysis” (29). No further clarification of pur- The Burton committee, less directly but more
pose was given to the committee, nor did any frequently supported research as critical to deal-
subsequent interaction occur between the com- ing with kidney disease. It tended to go beyond
mittee and the Surgeon General, the Assistant a limited endorsement, however, and suggested
that research was likely to generate substantial tients at $611 million, and of a f i f t h - y e a r
future reductions in deaths from ESRD. population of 102,000 at slightly more than $1
billion (in 1967 dollars). In fact, as noted above,
On prevention, the Gottschalk committee de-
clared that a screening program for pyelone- the committee’s report to the Surgeon General
phritis, glomerulonephritis, and polycystic kid- indicated that an annual cohort of only 8,000 to
ney disease made very little sense. The Burton 10,000 individuals would be serious candidates
for a treatment program “in the near future”
committee essentially said the same thing, but
couched its findings in language which obscured (17). Neither patient population nor associated
cost estimates for this most likely annual patient
that conclusion. The Burton committee did,
however, emphasize the prospective benefits in cohort were developed in the report, however,
so the astronomical cost estimates based on the
reduced deaths from ESRD due to prevention of
hypertension, a matter on which the Gottschalk unlikely 40,000 annual patient cohort stood by
implication as the committee’s contribution to
commit tee was silent.
the policy discussion.
It was on the issue of treatment for ESRD,
however, that the two committees diverged These discrepancies between the Gottschalk
most sharply. The Gottschalk committee used and Burton committee reports might have been
the treatment of ESRD as its point of departure. unimportant t save for the circumstances of their
That committee focused exclusively on patients release to the public. Initially, BOB had planned
who were dying from chronic kidney failure, to keep the Gottschalk committee’s report secret
hence candidates for treatment by hemodialysis and present it only to the BOB Director. News
or transplantation. The two forms of therapy, of the committee and its work leaked out to the
its report declared, were “sufficiently well ad- press, however, resulting in some publicity in
vanced today to warrant launching a national April 1967 and the certainty that the final report
program” (31). For the Burton committee, by could not remain secret (38). But BOB itself,
contrast, a universal treatment program repre- confronted with the fiscal implications of a na-
sented one “extreme” of policy possibilities, the tional ESRD treatment program, and increas-
“maximal benchmark” of how far the Govern- ingly feeling the effect of Vietnam war demands
ment might go. on funds for the Great Society programs,
walked away from the Gottschalk committee’s
The Gottschalk committee estimated 3,662 report.
patients in the first year of a treatment program,
increasing to 18,500 in the fifth year. The cor- BOB’s retreat from the Gottschalk report was
responding costs were $40 million to $49 million manifested in several ways. Dr. Burton recalls
for the first year, and $157 million to $205 that BOB was unwilling to publish the report,
million in the fifth. Cost estimates were based and he authorized payment for publication of
on the assumption that half of all dialysis pati - .500 copies out of the budget of NIAMD’s arti-
nts were treated at home at an annual cost of ficial kidney program. The cover of the report
$4,000 (low estimate) or 5,000 (probable esti- carried only the title and date, Report of the
mate). The estimated annual costs for center Committee on Chronic Renal Disease, Septem-
dialysis ranged from $10,000 (low estimate) to ber 1967. Inside was a transmittal letter from
$14,000 (probable estimate). Roughly 20 per- Dr. Carl Gottschalk to BOB Director Charles
cent of the total beneficiary population, i t was Schultze, but no official acknowledgment of
estimated, would receive a transplant, the costs receipt by the Director. Finally, the manner of
of which ranged from $10,000 to $13,000. Esti- the report’s release revealed BOB’s desire to put
mates about the patient population ( table 8) ex- distance between itself and the report from its
plicitly assumed that growth would be con- commit tee of experts.
strained by available facilities.
The Burton report to the Surgeon General
The Burton committee established the costs of was completed in late July, the Gottschalk
a treatment program for 40,000 first-year pa- report to BOB in mid-September. The political
question became how to release these reports in within the PHS kidney disease control program
a way to minimize public pressures for an ex- to promote a greatly expanded treatment pro-
panded ESRD treatment program. A “low key” gram.
approach was agreed on, and strategy was co-
ordinated between Joseph Califano on the White The Burton report was well received by Wil-
House staff, BOB Director Schultze, and HEW liam Gorham, the HEW Assistant Secretary for
Secretary John Gardner (3). The two reports Planning and Evaluation, by Dr. Alice Rivlin,
were released simultaneously at a PHS press his deputy, and by Dr. Philip R. Lee, the Assist-
conference on November 3, 1967. ant Secretary for Health. Others in HEW were
less responsive. Dr. Burton recalls briefing Sec-
The press conference itself engendered some
retary Gardner on the study for 11/2 hours short-
hard feelings. Dr. Gottschalk was notified of the ly before the Secretary’s resignation in early
press conference by telephone in Chapel Hill,
1968 and receiving only a noncommittal “Thank
N. C., only 12 hours before it was scheduled,
you very much” in return. Robert Grosse, an
and he was unable to attend. Dr. Robert Ber-
economist involved in HEW’s effort to improve
liner, then intramural research director of the
resource allocation by using formal analysis,
National Heart Institute, and technically an “ad- described the kidne y disease group’s work
viser” to the Gottschalk committee, was present
favorably but uncriticall y in several papers
to represent the expert committee. Since BOB
(11,12,13).
had refused to take any position on the Gott-
schalk report, however, Berliner was unable to
make other than perfunctory comments about One effect of the Burton report, noted above,
it. Dr. Burton, on the other hand, was under was to engender hard feelings among some
fewer inhibitions regarding the report from his members of the Gottschalk committee and those
in the medical communit y who were favorably
committee. The reporter who covered the story
for Medical World News wrote that the feature disposed to the Gottschalk report’s recommen-
dations. These hard feelings arose from the
of the briefing was not the report of the Budget
belief that the Burton study group, by its im-
Bureau’s expert committee, but the PHS report
plicit attack on a national treatment program
to the Surgeon General which emphasized re-
and by the circumstances surrounding the pub-
search on preventing kidney disease rather than
lic release of the two reports, had sought to
treating it. Dr. Burton reportedly called the
sabotage the report of the Gottschalk commit-
Gottschalk committee report “shortsighted.” “In
tee.
the long run, ” he was quoted as saying, “we
want to get rid of the infectious mechanisms
leading to kidney disease” (6). ” Three factors contributed to this impression
of sabotage. First, the reasons behind the PHS
Policy and Program Effects study were never clear. Why study kidney dis-
ease when it was known that a BOB committee
What were the policy and program effects of was at work on the subject, many reasoned, if
these two formal analyses? The Burton report not to prevent PHS from being outflanked on an
had little direct effect on PHS policies or pro- issue of some importance to it? PHS was not en-
grams in kidney disease. For one thing, the Sur- tirely clear on this point. It recognized that the
geon General’s charge precluded the study real policy problem was the treatment issue, but
group’s making any recommendations. In gen- did not address this matter directly in the charge
eral, the Burton report reinforced NIH research to the study group. The PHS study group,
programs related to dialysis and transplantation moreover, acknowledged that the cost of a na-
and supported PHS efforts in prevention. It tional dialysis and transplantation treatment
countered, to some degree, the pressures from program was beyond its charge, but neverthe-
less chose to conclude its report on that subject.
‘‘Burton recalls speahlng ot Immunological” mechanl>rn~ In con- The purposes and motives of PHS were thus
nection with glomerulonephrlt” i~ called into question.
Second, BOB’s motives and behavior in walk- who were treating patients. Controversy existed
ing away from the report by its committee of ex- throughout the early 1960’s about whether dial-
perts were not widely understood. Irving Lewis ysis and transplantation, especially the former,
recalls the occasion when Dr. Gottschalk were experimental or established treatment. The
briefed BOB Director Schultze on the report: report of the Gottschalk committee declared
Schultze praised the work of the committee and that dialysis and transplantation were “capable
its report, but said that resources for new of prolonging life” and were “sufficiently well-
domestic initiatives were increasingly scarce as a advanced today to warrant launching a national
result of the impact of the Vietnam war (22). program, ” The impact of this declaration was
BOB, consequently, sought to dampen the im- summarized several years ago by one prominent
pact of the Gottschalk committee’s report in the clinician in this way: “It was not until 1967 and
ways described above. the Gottschalk report that you had for the first
time an expression of national opinion that dial-
Finally, hard feelings arose from the absence
ysis and cadaveric transplantation were ther-
of communication between the two committees.
apy” (39).
Interaction between the two groups did occur
through several formal and informal means, but The third effect of the Gottschalk report was
these were limited in scope and duration. A on the VA’s renal program, which had precipi-
single meeting of the two committees in the tated the formation of the committee. There was
spring of 1977 would have clarified for each created within VA a home dialysis program
other their respective missions and perhaps which came to dialyze a significant portion of
would have facilitated a more clearly under- the veteran dialysis patients. A secondary effect
stood division of labor. on VA was to encourage the development of its
transplantation program in a select number of
The Gottschalk committee and its report rec-
VA hospitals and to encourage the advocacy of
ommending a national ESRD treatment pro-
transplantation programs within the PHS pro-
gram had greater effects than the Burton com-
gram as well.
mittee and its report, because the Gottschalk
committee was a group with high status in The question arises about the effect of the
academic medicine, and advisory to BOB in the Gottschalk report on subsequent legislation,
Executive Office of the President. The commit- especially upon the extension of medicare cover-
tee’s effects were of four kinds. The first was to age to ESRD through the inclusion of section
neutralize opposition to dialysis and transplan- 2991 in Public Law 92-603, the Social Security
tation within the academic medical research Amendments of 1972. After the committee’s
community by making clear that these therapies report, several bills that incorporated the re-
were established and not experimental and by port’s recommendations were proposed in Con-
convincing the community that the patient load, gress, but none was enacted. In 1970, the heart
and thus the economic burden, was predictable. disease, cancer, and stroke legislation was
Dr. George Schreiner recalls that representa- amended to include kidney disease, the only leg-
tives of foreign countries who testified at the islative enactment on the subject occurring be-
committee’s second meeting, held at the same fore Public Law 92-603.
time as the International Congress of Nephrol-
Dr. George Schreiner, member of the Gott-
ogy, all reported that the incidence of good dial-
schalk committee, served as president of the Na-
ysis candidates each year was in the range of 56
tional Kidney Foundation from 1969 through
to 58 patients per million population. Certain
1971. In that capacity, and aided by Charles
predictabilities existed. The committee’s work,
Plante r Washington representative of the foun-
Schreiner remembers, “gave a much broader
dation, Schreiner used the report, in his words,
vista to the scientific types like Gottschalk,
“as a two-by-four to get the mule’s attention. ” In
Seldin, and Berliner” (40).
numerous one-on-one discussions with individ-
The converse effect of the Gottschalk commit- ual members of Congress and their staff, the
tee’s work was to sanction the work of clinicians Gottschalk report was cited as evidence of the
importance of treating ESRD. That report, with the Gottschalk report’s recommendation.
therefore, helped clinicians advocating a treat- The statute and implementing regulations for
ment financing effort. Schreiner was emphatic, the medicare renal program differed in two re-
however, that legislation would never have oc- spects, however, from major recommendations
curred because of the report (40). of the report. First, whereas the Gottschalk
committee recommended a strong emphasis on
Within the Bureau of Health Insurance of the
home dialysis, the medicare program inadver-
Social Security Administration, Irwin Wolk-
tently introduced disincentives to that form of
stein, Deputy Director for Program Policy,
treatment (32). Second, the report recom-
remembers reading the Gottschalk report and
mended a Federal investment in the “supply”
talking about it with Klarman. The Bureau of
side of treatment facilities and trained medical
Health Insurance as an organization, however,
professionals. In 1972, though the needs on the
had deep reservations about extending health
supply side were less than those 5 years earlier,
insurance coverage on a categorical disease
no consideration was given to this Federal
basis. The Gottschalk report per se generated no
assistance, and the statute focused exclusivel y
advocates for its recommendation within medi-
on augmenting the “demand” side by financing
care (45). Neither the staff of the House Ways
patient care.
and Means Committee nor the Senate Finance
Committee had read the report at the time of the
In summary, the Gottschalk committee report
1972 legislation.
had little direct effect on the 1972 resolution of
The 1972 legislation, however, did extend the policy question of financing patient care.
medicare coverage to those with ESRD under The effects on the scientific and clinical com-
the general extension of coverage to the dis- munities, of course, may have indirectly in-
abled. In this respect, the statute was consistent fluenced the subsequent course of events.

CONCLUSIONS
What general conclusions can be drawn from several instances of underlying optimism about
this study about the use of formal analysis in probable developments in medical research and
policy formulation? First, policy toward ESRD practice. The Gottschalk committee was overly
was always governed by two rudimentary facts optimistic about transplantation, the Burton
concerning treatment for ESRD: Such treatment committee about research and prevention. If
was costly and lifesaving. These facts were un- analysis is based on limited and inadequate
changed by analysis; nor did analysis alter data, as it usually is at the early stages of policy
perceptions of what policy ought to be. Some formulation, it is then quite difficult to separate
shrank from the large cost implications of a na- realistic from overly optimistic expectations
tional treatment program: How can we afford about the future. A critical review of basic
such an expensive effort for so few? Others assumptions by experts not involved in the
reacted to the benefits: How can we withhold analytical effort may be the best corrective to
lifesaving therapy simply because people lack this source of bias.
the means to pay for it? Analysis did not alter
Third, formal analysis on allocating resources
the fact that the policy issue was a basic political
for lifesaving therapy cannot be done in secret.
choice between scarcity on the one hand, and
Though the original intention of BOB was to
the priceless value of life on the other (s).
secure expert judgment from the Gottschalk
Second, it is important to recognize that ex- committee on a confidential basis, leaks to the
pectations of progress infuse practically all do- press, the resultant publicity about a “secret” ef-
mains of science and technology, includin g fort, and congressional inquiries eventuall y
medicine, Indeed, in this analysis, we witness forced the analyses to be released (7). PHS, on
the other hand, always intended to release the had access mainly to the higher officials in
Burton committee’s report, and its intentions HEW. An additional, and closely related, point
placed further pressure on BOB to release the is that analysis has its greatest effect when pol-
Gottschalk report. It is the case, however, that icymakers wish to use it and have access them-
the Government has substantial discretion in selves to instruments that affect policies and
how it releases reports, and can choose to do so programs. The influence of the Gottschalk com-
in ways that enhance or diminish the impact of mittee report, in large measure, was confined to
recommendations. VA, because BOB could influence VA directly
through the budgetary process and because it
Fourth, the absence of major policy action in
consciously shrank from the report’s larger im-
response to the Gottschalk and Burton reports
plications.
does not mean that these efforts had no impact.
Certainly, these reports did raise the conscious- Finally, it should be noted that analysis done
ness of policy makers at the highest levels of for purposes of policy formulation is likely to be
Government to the substantial cost implications limited by a number of factors. The statement of
of action, Given that the Vietnam war was the problem will control the analysis and its out-
absorbing increasing proportions of national comes. Data are likely to be inadequate, espe-
resources at the time, it is not surprising that cially for issues just coming to policy prom-
nothing happened. 16 The effects of greater even- inence. Assumptions are required on critical
tual policy consequence were those on the sci- issues. Estimates are based on assumptions and
entific and clinical communities, including inadequate data. Normative preferences will be
strengthening clinician advocacy on behalf of found explicitly or implicitly throughout the
treatment financing. analysis. Projections over time are highly sen-
Fifth, analysts have their greatest effect when sitive to the estimates, assumptions, and data.
they have direct access to key policy makers Uncertainty may inhere in clinical practice
(23). The expert advisory committee to BOB which cannot be reduced by formal analysis but
had access to the BOB Director, to the Office of only by the increase of scientific knowledge.
Science and Technology, and to the White Given these limitations, the large conclusions of
House. The members of the PHS study group formal analysis are likely to be most important
— to policy formulation if the estimates, assump-
‘“~ottschalk recalls that BOB ottlclals told hlm early In the w’ork tions, and data appear to be reasonable. Formal
()[ the corn m i t tee that the anal ySIS was undertaken, In part, to cre-
ate a pol ]cy opt Ion I n the event peace arrived I n Southeast ASla. analysis may augment policymaking; it cannot
Lewl~ has no such recollection”. substitute for it,

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