When we book an airline flight, we often have the option of paying extra to upgrade to business or first class. We can choose higher levels of comfort and amenities if we can afford them.

Many hospitals offer private rooms with additional services to patients who wish to be in a distinct environment.  When patients sign up for in-center hemodialysis (HD) treatment in a dialysis clinic, however, there is only one option. Some dialysis centers have isolated rooms, but they are usually used for patients with hepatitis B infection.

Historically, with the implementation of end-stage renal disease (ESRD) legislation in 1972, the first exception to the Medicare eligibility threshold age became reality in this country. Patients younger than 65 years would be a Medicare beneficiary when they needed chronic dialysis treatment to survive.


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Whereas the ESRD program is a proud legacy, and an exceptionally expensive benefit for taxpayers, it has an overarching homogeneity in its format and pattern of services. Dialysis centers have a rather uniform and basic operation, and providers do not offer anything above and beyond what is already offered to everybody.

Patients cannot choose to pay for extra services because there are no extra services to buy. Is this highly uniform patient care what we strive for in our quest for excellence in patient care?

I would like to pose a provocative question: If the fundamental dialysis care is provided to all ESRD patients, would any heterogeneity in the choice of additional services be unethical or implausible?

A dialysis patient should have a choice to pay for extra services, such as accommodation in an isolated area or an executive suite, access to private bathrooms with showers, 5-star level meals prepared by a special cook, watching recently released movies on a large screen, and so on, all of which while receiving HD treatment in a rather distinct environment. Can we not have dialysis centers with 2 or more levels of patient services, including business class and first class tiers?

In California and some other states, we are fortunate that we can offer maintenance dialysis treatments to illegal immigrants with ESRD. Now that we provide this life-saving treatment to more than 400,000 patients in our country, we should be able to have additional choices for those who wish to experience a different experience during their 3-times-a-week visits to dialysis centers.

Having the option of paying for additional services does not discriminate against those patients who cannot afford them. It would promote more innovation in the dialysis industry and engender creativity and motivation to work harder. Differences make us strong.