Belgium has a mixed, public-private health care system, with state-organized reimbursements but private providers. The system is fee for service. For end-stage renal disease (ESRD), the fee-for-service system discourages preventive strategies, early referral to the nephrology unit, and the use of home-based therapies. The aging of the general population is reflected in the rapidly increasing number of very old dialysis patients, requiring more complicated and, therefore, more costly care. As dialysis costs increase, the ability to provide unrestricted access to dialysis treatment may be unsustainable. To aid in decision-making processes, nephrologists must be aware of financial and organizational issues.