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New study highlights poor standard of care in for-profit U.S. dialysis clinics

ProPublica, a public interest non-profit, badgered the data collectors at Medicare for two years to secure, through the Freedom of Information Act,  a copy of the Agency's information related to dialysis care in the United States.  While they only recently received the wealth of (taxpayer-funded) data, they were able to publish some eye-opening and distressing information in an article that has been widely quoted in the media this week.  Most distressing:  despite spending far more money on dialysis care, the U.S. experiences far more complications and fatalities than any other non-third-world nation.  Our complication rate is far higher than the rate in Italy, Germany, Japan and France, for example, despite the fact that 80 percent of U.S. dialysis clinics are run by for-profit corporations. 

Taxpayers spend $20 billion dollar a year--$77,000.00 per patient--fully six percent of the Medicare budget--on dialysis-related care for 400,000 patients annually.  Yet we have one of the industrialized world's highest mortality rates. The two corporations that dominate in providing this care reported about $2.2 billion dollars in operating profits per year, according to the organization.  The non-profit traces the disconnect between cost, profit and outcome to several factors including a fee-for-service payment system that takes no account of patient outcomes (it doesn't award low mortality, hospitalization or infection rates, or punish unusually high rates) and a related decision several years ago to allow dialysis clinics to charge a premium for administering prescriptions.  The two for-profit entities that dominate U.S. care through their ownership of than two-thirds of the country's 5,000 for-profit dialysis clinics are Colorado-based DaVita and Fresenius, a subsidiary of a Germany dialysis machine manufacturer.

The report noted that the manner of payment also encourages for-profit providers to minimize patient contact with physicians and nurses and the Medicare regulations allow treatment "technicians" to form the backbone of dialysis care in the U.S. with virtually no training or education required initially.  In the U.S., clinics rarely have a doctor on-site, although they are required to pay a "medical director."  Many struggle to maintain the requirement of one R.N. on site--a far cry from European countries where nurses are limited to a 3.5:1 patient to nurse ratio. 

In the U.S., dialysis treatment has been compressed to well under four hours in many locations, despite the clearly deleterious impact of rushing treatment.  While many European dialysis clinics limit care to two shifts per day, some U.S. clinics squeeze in four shifts per da, despite the fact that condensing dialysis into less-than-four-hour blocks elevates blood pressure and interferes with hemodynamic stability.  Medicare has established no regulations for staffing or for duration of dialysis treatment. 

Inspection reports show that many clinics are inspected only once in five years, rather than every 3 years as theoretically required--and reports of filthy or unsafe conditions are neglected despite repeated threats of sanction or closure.  The reports also document hundreds of examples of infection-control breaches, cross-contamination of blood, prescription error, and injurious or fatal events related to internal or external hemorrhaging caused by equipment failure, technician error or prescription dosage error.

One of the complications in regulation that had a deleterious impact on both the cost and the quality of care was the decison to reimburse drug administration at a mark-up.  "Doses of Epogen, to treat anemia, and similar medications tripled between 1989 and 2005, becoming Meidcare's single largest pharmaceutical expense"...despite the fact that a 2006 study showed that patients treated with higher doses of Procrit--a similar medication--were at greater risk for heart problems and death.   European dialysis clinics dose their patients with a far lower dosage of these medications--but low dosage requires a willingness not to rush the dialysis procedure.

In 2008, one-quarter of dialysis clinics had a profit margin of at least 13%, while another quarter lost money, according to the Medicare Payment Advisory Commission.  Some of this discrepancy is a direct result of the government's short-sighted payment variables which emphasize fees for service and pharmaceutical administration, while minimizing payment for medically-trained staff.

Even today, the government refuses to publish mortality data where it would be available to patients making treatment choices.  As a result, ProPublica was able to identify examples like Houston, Texas,  where two clinics two miles apart have dramatically different survival rates--but patients don't have a clue and can't protect themselves or their loved one by identifying and choosing the safer alternative. 

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