we all focus on the dialysis treatment and outcomes but I feel a big issue is that the dialysis settings have been charged with the modality aspect renal care. Under the umbrella falls anemia, bone, iron, nutritional, adequacy, and vascular access management. Of these access management and adequacy are really the treatment related outcomes that can be totally managed on site. The others anemia etc, are really co morbid conditions that cannot be managed solely by the treatment, they are part of the disease and are responsible for other disease processes. There is just not enough time nor staff to holistically manage these parameters, The treatment for anemia bone and iron just happen to be able to be administered via the treatment so the disease management is now part of the hemo treatment. This would be ok but the reimbursement rate is for a treatment. I believe CMS looking at outcomes is a great step forward but the quality of life for these patients stems from far more than a treatment. The nephrologist cannot oversee the entire patient from dialysis rounding. The dialysis clinic has become the primary care setting for many patients, I have been a nephrology nurse since 1967 and am a bit ideal I realize that, I think there needs to be comorbidity management and management of the disease process beyond that of the treatment. Units are not being paid to manage disease or co morbidities but to provide safe, efficient, adequate(not optimal) renal replacement therapy.