The achievement of quality care is the goal of all health care providers. Today's environment of health care reform and cost containment provide added challenges to achieve the balance between costs and quality. The End-Stage Renal Disease Program has faced cost-containment restraints more stringently than any other Medicare provider. Twenty years of fixed reimbursement coupled with periodic reductions have placed barriers in the attempt to achieve quality patient care. The administrators of these programs have been faced with slicing the reimbursement pie differently in reaction to changes in the costs incurred by the facility and by the erosion of reimbursement by inflation alone. No other Medicare provider has been subjected to this type of constraint. However, the facility must achieve quality patient care to ensure its financial viability. Patients who are dialyzed properly and adequately provide a longer and more consistent source of revenue for the facility. The end-stage renal disease industry as a whole needs to establish guidelines for the care received within the facility. Only through a systematic linkage of cost and quality measurements can the program hope to provide quality patient care.