[Disclosure: I’ve been a DaVita dialysis patient since February 2000. I keep a detailed history of my blood chemistry and I receive healthy doses of Epogen. Without it, I would be absolutely miserable. As it is, when my hemoglobin level falls below 11.5 g/dL I’m in bad shape. My experience with DaVita and my nephrologist is that my anemia is adequately managed and, if anything, my Epogen dosages are conservative. Three times a week I’m astounded by the professionalism and generally excellent quality of care I receive from the nurse and dialysis technicians at DaVita’s Highland Park facility in Saint Paul. They, as individuals, keep me alive.]
The Denver Post has a package of articles about dialysis provider DaVita, who relocated to Denver last year. In “Kidney-dialysis titan DaVita defends patient care, business practices,” Christopher N. Osher, Jennifer Brown, and Michael Booth rehash DaVita’s profit-padding through dangerous overuse of Epogen in its patients. While there’s little new here that hasn’t been reported elsewhere years ago, Osher, Brown, and Booth do a really good job of explaining what Epogen is, why it’s used in dialysis patients, and the problems associated with it. They note that DaVita’s use of Epogen to raise its patients’ hemoglobin levels is historically the highest in the industry.
The Post writers report that DaVita began using a new protocol in December 2010—just before the Medicare bundling rule took effect—recommending that doctors stop Epogen when a patient’s hemoglobin level rose above 12 g/dL. The company’s previous protocol called for ceasing Epogen only when a patient’s hemoglobin level was above 14 g/dL—a level found to be a death risk by the US Food and Drug Administration (FDA). As of January 2011, Medicare would no longer pay for Epogen separately (to the tune of six percent more than the dialysis provider paid the manufacturer and responsible for 18 percent of DaVita’s 2010 revenues) from dialysis treatments; all services and intravenous drugs would be “bundled” into a single payment.
Osher, Brown, and Booth let DaVita’s anemia-management expert, David Van Wyck, bamboozle them on one point. When asked why there were so many more DaVita patients with hemoglobin levels higher than 12 g/dL than its competitors and why the company changed its protocol, Van Wyck claimed that the Medicare bundle had nothing to do with it, attributing the changes to “a combination of evolving science, the additional Epogen guidelines approved by the FDA in 2010, and new Medicare quality-improvement measures that reward dialysis companies for having more patients’ hemoglobin levels within the 10-12 range.” Van Wyck went on to tell the Post reporters that “the latest protocol marked the first time DaVita figured out how to cut off Epogen when patients reach level 12 without causing too many patients to slip below level 10. ‘It was a huge accomplishment.’”
Well, not really. Epogen is prescribed for each patient, by the patient’s nephrologist, on an individual basis. When anemia management problems are present, additional blood draws are done to assess hemoglobin levels and the Epogen dosage is adjusted accordingly, sometimes on a daily basis. The idea that one patient’s hemoglobin level or Epogen dose is related to another’s is simply false.
The Post reporters cite Dennis Cotter, president of the Medical Technology and Practice Patterns Institute, as saying there have been no new scientific discoveries that would explain DaVita’s protocol change and estimating that DaVita would use half as much Epogen under its new protocol, saving millions of dollars. Osher, Brown, and Booth cite Ajay Singh, an associate professor at Harvard Medical School, as saying Epogen use has remained high in clinics operated by for-profit dialysis providers “until the changes in government reimbursement were on the horizon.” Singh ran the clinical trial in 2006 finding high Epogen doses to be a death risk.
The article explores a federal investigation of DaVita regarding “false or otherwise improper claims” to Medicare and Medicaid, an investigation by the St. Louis US attorney into DaVita’s Medicare reimbursements, two whistle-blower lawsuits (from a former clinic director and Epogen accounts manager) and quotes DaVita chief executive Kent Thiry as saying, “In some cases, playing it totally safe would be the same as unilaterally disarming and exiting the market. And so, this is not to say we predict we’re going to go the next 10 years without having to issue a check, that that wouldn’t be prudent rather than go through a couple-year battle.”
As Osher, Brown, and Booth write in closing the article, “The nation’s system to pay for dialysis during the past decade was not designed to optimize patient care, the independent Medicare Payment Advisory Commission has reported to Congress.” They quote David Spiegel, professor at the University of Colorado and its chronic hemodialysis program coordinator: “The mission of corporations is really for their bottom line and their stockholder. The mission of a health care company is to do what’s in the best interest of the patient. When you merge those two worlds, you are potentially asking for and setting up situations of conflicts of interest and maybe misaligned incentives.”
Jennifer Brown’s lede in “DaVita lets patients reuse filters, now a less-common practice in industry” is misleading. In my experience, DaVita quite strongly recommends reusing dialyzers, in order to reduce costs and increase its profits. Brown cites a 2007 paper in the Clinical Journal of the American Society of Nephrology finding no medical need for dialyzer reuse. Brown also reports on two Colorado Springs DaVita patients who were given the wrong dialyzers—from other patients with hepatitis C and MRSA, respectively. And in 2007 a Michigan DaVita patient died when the dialyzer cleaning agent wasn’t properly removed.
Michael Booth’s “Some patients appreciate benefits in for-profit kidney-dialysis system” is a short profile of an 82-year-old Korean War veteran who appreciates how easy the corporate dialysis providers make travel.
An unbylined story, “A detailed summary of investigations into DaVita,” provides an excellent overview of US federal investigations of the dialysis provider and current litigation in which its involved. DaVita representatives stress that the company has never settled a federal claim and that patient care is always paramount.
Under US law, the sole purpose of a corporation is to return value to shareholders. If patient care is more important to DaVita than financial return to shareholders, the company is in violation of federal law. Just saying.
Allen R. Nissenson, DaVita’s chief medical officer, offers the company’s perspective in “Guest Commentary: DaVita CMO: We’ve been transparent.”
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