ARTS & FARCES internet

DaVita, one of the US’s two largest corporate dialysis providers, has plans to move into providing primary healthcare services for dialysis patients according to Michael Booth writing for the Denver Post. Here’s why: “DaVita, with US$7 billion in revenue, manages about US$33,000 a year in Medicare spending for each of its 142,000 dialysis patients,” reports Booth. “But those chronically sick patients spend another US$55,000 a year in Medicare money for other conditions, from diabetes to heart failure.” It’s all about the money—more of it, to be specific—even though those figures don’t include patients—like me—with private insurance who are even more lucrative.

DaVita wants to partner with doctors and hospitals, creating accountable care organizations (ACOs)in order to contract with Medicare. If ACOs meet quality standards while cutting costs, they’re allowed to split the savings with Medicare.

Bill Peckham, of Dialysis from the sharp end of the needle, tells Booth precisely what’s wrong with this picture: “You’re substituting business ethics for medical ethics, and I think that’s a bad deal.” Peckham goes on to note that the ACO model “encourages withholding of care to save money and create profit-sharing.”

Peckham reveals DaVita’s corporate double-speak as indicative of its perception of its patients:

“[DaVita chairperson] Thiry calls himself ‘The Mayor,’ and employees ‘citizens’ of the DaVita ‘Village.’ Where does that leave the patients? We’re the ‘crop.’ We’re the ‘ore’ in the mines. That’s not a fun place to be if you’re the person who needs dialysis.”

Just about three years ago, I wrote about David Jacobs’s paired organ donation solution to the transplant organ shortage. He launched his paired organ donation software at the DEMO conference that year. I assume it’s been in continuous use, but I haven’t heard much about it and note that there’s only a single partner hospital.

Paired organ donation is the process by which a person who needs an organ has a donor that’s incompatible with her but that is compatible with someone else waiting for an organ. Very complex paired organ donations can be accomplished with hundreds—even thousands—of organ donors and recipients.

Paired organ donation doesn’t require a “Good Samaritan” to initiate the chain reaction, only a willing donor that’s incompatible and still willing.

Kevin Sack, writing for the New York Times reports on a 60-person kidney donation chain that started with a single “Good Samaritan.” (The Times‘s multimedia presentation related to Sack’s story is also available.) The donor didn’t have an intended recipient; he merely called Riverside Community Hospital in Riverside, California and asked how he might become a kidney donor, expecting nothing in return. Until quite recently, hospitals routinely turned away “Good Samaritan” donors, thinking them to be unstable. That man’s altruistic action set a chain reaction in order as incompatible but willing donors decided they would still be willing—even for a stranger.

Peter Laird is an internist who also happens to be a dialysis patient. He writes regularly about the plight of dialysis patients from a unique perspective. In his most recent article, The dialysis industrial complex, he draws the parallel between Eisenhower’s military industrial complex and the current relationship between the US government and dialysis providers. “Despite the best intentions of the 1973 ESRD program, gross deficiencies in quality are rampant throughout the industry where profits continue to soar,” writes Laird.

Dialysis in the US started as a grand experiment to keep kidney failure patients alive, productive, and well but has devolved into the worst treatment program in the developed world. How that happened, as Laird notes, is subject to debate, but the fact it has is not in dispute.

As the provision of dialysis services in the US was commercialized, quality went down and mortality and morbidity rose in proportion to corporate profits. “Today, Davita and Fresenius dominate the American market with the most expensive dialysis population and the world’s worst outcomes,” Laird reports. Laird traces the qualitative shift in provision of dialysis services to the 1978 congressional testimony of Edmund G. Lowry, then vice president of National Medical Care, condemning “an entire generation of dialysis patients to short, violent sessions coupled with daily nausea, vomiting, severe fatigue, cramping and bouts of syncope.”

The dialysis community has known for quite a while that longer sessions combined with lower blood flow rates yields higher quality dialysis with fewer problems. But it’s not economically feasible in a system that rewards only the shortest treatment cycles.

Laird goes on to note the rarity of an academic nephrology study that makes an actual recommendation (other than that additional study is needed).

The Centers for Medicare & Medicaid Services (CMS) has published its final rule (.pdf; 872KB) of its 2012 End-stage Renal Disease (ESRD) Quality Incentive Program (QIP). As expected, the final rule includes the controversial decision to eliminate the minimum hemoglobin standard that’s been in place for years. It also increases the dialysis reimbursement in 2012 by 2.1 percent. While most ESRD hemodialysis patients are also Medicare beneficiaries, some of us remain on private insurance policies. It doesn’t matter, as the dialysis providers universally adhere to the minimal CMS guidelines as a matter of course.

Over the past 20 years, dialysis providers made a bundle of money by overusing erythroipoiesis stimulating agents (ESAs)—most commonly Erythropoietin (EPO)—to raise hemoglobin levels in dialysis patients. Pharmaceutical companies urged nephrologists to prescribe, and dialysis providers to deliver, recklessly high dosages of these drugs all in the name of outsized profits. As a result, Medicare now pays a flat fee for a “bundle” of services—known as the Dialysis Bundle (which took effect 1 January 2011)—rather than paying for each service separately. As I’ve written before, I’ve been a dialysis patient for almost 12 years and my hemoglobin level never rose to the levels of an anemic non-ESRD person in all that time. In fact it only rose above 12 g/dL two or three times, and then only for a day or two. That doesn’t mean that overuse of Epogen isn’t a problem—it absolutely was—just that it wasn’t a problem for me.

Under CMS’s final rule, two metrics will be used to determine treatment efficacy in dialysis patients in 2013: hemoglobin levels greater than 12 g/DL and a urea reduction ratio (URR) of at least 65 percent. Under the QIP, payments to dialysis providers are reduced if they don’t achieve an acceptable performance score with regard to these two metrics. In 2014, the efficacy metrics will be expanded to include the percentage of patients receiving dialysis through a arteriovenous fistula, whether or not the dialysis provider reports dialysis-related infections to the Centers for Disease Control & Prevention’s National Healthcare Safety Network, whether or not the dialysis provider administers a patient experience of care survey, and whether or not the facility monitors phosphorous and calcium levels on a monthly basis.

On 24 June 2011, the US Food and Drug Administration (FDA) announced that there is “no risk-free dosage level” of the most common ESAs, Epogen, Aranesp, and Procrit and that these drugs should be used only to reduce the need for blood transfusions. Oh, joy.

Three years ago, when kidney transplants were failing at twice the normal rate and at least five transplant patients died at the University Medical Center in Las Vegas, the Centers for Medicare and Medicaid Services moved to decertify the hospital’s kidney transplant program. US Representative Shelley Berkley (D-Nevada) intervened, along with two other members of the Nevada delegation.

The difference, according to Eric Lipton, writing for the New York Times, is that Berkley’s strong-arm tactics directly benefitted Larry Lehrner, her nephrologist husband. Lehrner “directs medical services at the hospital’s kidney care department—an arrangement that expanded after her intervention and is now reflected in a US$738,000-a-year contract with the hospital,” reports Lipton. “Ms. Berkley’s actions were among a series over the last five years in which she pushed legislation or twisted the arms of federal regulators to pursue an agenda that is aligned with the business interests of her husband, Dr. Larry Lehrner. In addition to the hospital contract, he operates a dozen dialysis centers in Nevada and has played a central role in an industry campaign to lobby members of Congress—including his wife—on behalf of kidney care providers.”

This illustrates exactly why the Stark Law was written: To prohibit physician self-referral (when a physician refers a patient to a medical facility in which he has a financial interest. Dialysis services are specifically excepted from the Stark Law under the “safe harbor” provisions of the law.

For an excellent analysis of the high stakes involved in the Stark Law exception for dialysis services, see Jennifer Brown’s excellent article for the Denver Post in 2009—just as dialysis provider giant DaVita was moving its headquarters to Denver—about sharp-elbowed approach to dealing with competitors.

My experience jibes with Brown’s reporting. My nephrologist group is closely-linked with DaVita and I’ve been told that if I moved outside of DaVita clinics no one in the practice would be able to see me. I have strong history with just about every partner in the group, and they’re individually and collectively the best in town, but they’re joined at the hip with a corporation where, as Brown cites in the Pikes Peak nephrologist group’s countersuit against DaVita, “‘cost-cutting measures and administrative bureaucracy’ were taking precedence over patient care.”

I’ve been a patient at two Saint Paul DaVita-owned dialysis clinics since 2000. I have excellent relationships with my nephrologist and DaVita staff and feel that I get excellent care. But I did switch clinics several years ago because the quality of care at my original clinic had degraded each year. The only competing option in the Twin Cities metro area is the second-largest dialysis provider in the US, Fresenius. As a non-Medicare patient, I’d really like to see competition for providing dialysis services in this market. And I’d just about kill for one of those heated massage chairs they have out in Denver.