Medicare Payment Regulations Found to Transgress Biological Principles, Exacerbating Inequities in Kidney Health Services
In a recent article published in the Health Affairs series, titled "Payment Systems Violate the Physics of Life: How ESRD Bundle Policies Disrupt Biological Order in Minority Communities," the Physical Laws Framework (PLF) is used to critique Medicare’s End-Stage Renal Disease (ESRD) payment bundles. The article demonstrates how these policies contradict the biological requirements of kidney function, causing harm, particularly among minority communities like Black and Hispanic populations.
The PLF, a scientific approach for evaluating healthcare policies, treats biological principles as immutable natural laws, similar to physical laws like gravity. It was developed to determine if healthcare policies support or contradict these biological realities. In the context of kidney disease policy, the PLF has shown that the Medicare ESRD payment system contradicts the biological necessities of kidney function, leading to measurable harm.
The article reveals that Medicare’s decision to bundle oral phosphate therapies into dialysis center payments creates a direct conflict with biological necessity. Phosphate levels must be controlled continuously, not just during dialysis sessions, and patients need immediate access to medications when biochemical imbalances occur. However, the bundling policy forces patients to obtain critical medications only through dialysis centers, eliminating pharmacy access and creating dangerous gaps in treatment.
This is particularly problematic for Black Americans, who comprise 35% of dialysis patients but face the greatest barriers under this system. They are more likely to rely on pharmacies and long-term care facilities now excluded from dispensing these life-sustaining medications.
Gary A. Puckrein, PhD, President and CEO of the National Quality Forum (NMQF), which developed the PLF, states that this framework gives an objective, scientific standard for healthcare policy, similar to how engineers must respect the laws of physics when building bridges. NMQF invites healthcare leaders, policymakers, clinicians, and patient advocates to engage with the Physical Laws Framework through various means, including visiting ConserveLife.org.
The article is part of a 15-part Health Affairs series running through March 2026, each installment applying PLF to different healthcare challenges. Upcoming events include a LinkedIn Live discussion with article authors on August 13, a webinar on "Applying Biological Laws to Payment Policy" (tentative), and the Cancer Equity Summit in November featuring PLF applications.
For more information about NMQF and the PLF, visit www.nmqf.org. The article can be found at this link.
The PLF provides a scientific standard for evaluating whether healthcare policies work with or against biological realities, with the goal of reducing disparities and improving outcomes. By aligning healthcare policies with the fundamental biological laws governing human health and disease progression, the PLF aims to ensure that healthcare policies support effective management and progression slowing in chronic conditions like kidney disease.
