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New Study Shows Higher Mortality Risk at For-Profit Dialysis Chains

A new study shows that patients treated at dialysis clinics run by the largest U.S. for-profit chains have a higher risk of death than patients treated by the biggest nonprofit chain.

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Dec. 10: This post has been updated twice.

Patients treated at dialysis clinics run by the largest U.S. for-profit chains have a higher risk of death than patients treated by the biggest nonprofit chain, a study released today in the journal Health Services Research concludes.

The outcome gaps are substantial: Patients at the largest for-profit chain were found to have a 19 percent higher risk of death than patients receiving care at the nonprofit; at the second-largest chain, the risk was 24 percent higher.

"The difference is very significant," said Yi Zhang, who led the study conducted by the Medical Technology & Practice Patterns Institute, a Bethesda nonprofit. "It's not five or seven percent. It's pretty dramatic."

The study also found that patients had a 13 percent lower mortality risk if they were treated at nonprofit clinics, regardless of chain ownership, than if they received care at for-profit clinics.

The study's findings are likely to stir debate because U.S. mortality rates for dialysis remain among the highest in the industrialized world -- one in five patients dies each year -- and because more patients than ever are getting their care from for-profit chains.

More than 80 percent of American dialysis clinics are run for profit. Chain ownership has increased more than 11-fold since the early 1990s. Two for-profit companies -- Fresenius Medical Care North America and DaVita Inc. -- now control about two-thirds of the market for dialysis care.

In a recent ProPublica investigation, some doctors, patients and advocates voiced concern that industry consolidation has winnowed down care options, thus reducing competition, and questioned whether providers' efforts to make money had affected quality.

Today's study does not identify chains by name, but Fresenius and DaVita ranked first and second in number of clinics in 2004, the start of the study period. Since then, they have acquired the two chains that were next in size. The largest nonprofit chain is Nashville-based Dialysis Clinic Inc.

A Fresenius spokeswoman said the company would not comment on the study's findings until it had a chance to examine them fully. DaVita officials said the study reflected an outdated version of reality.

"This study examines seven-year-old data, and significant changes in the way dialysis care is delivered have been made in the more than half a decade since, with continued overall improvement in patient outcomes," the company said in a written statement.

More recent information from the federally funded U.S. Renal Data System (USDRS) shows that large dialysis providers achieve better mortality outcomes than nonchain or hospital-based facilities, the DaVita statement added.

The MTPPI study excluded patients treated in hospital centers -- a key difference with some previous studies -- because they tend to treat patients with more complicating conditions, government data show.

In comparing chains to each other, however, the study's results largely mirror those in reports by the USRDS showing that Dialysis Clinic Inc. has lower mortality and hospitalization rates than other large dialysis providers.

The study tracked about 34,900 Medicare patients who started dialysis in 2004 at 3,601 free-standing clinics, following them for two years. Medicare pays for most dialysis under an entitlement created in 1972.

Researchers compared outcomes at the five largest dialysis chains -- four for-profits and one nonprofit -- and at nonchain clinics. They adjusted data for differences in patient mix, as well as for facility size, staffing, geographic disparities and income inequality.

In addition to lower mortality risk, the study found that patients at the nonprofit chain had the shortest hospital stays and were most likely to be in the recommended range for anemia, despite being given the lowest doses of anemia-treatment drugs. Its clinics also were staffed differently, with more nurses relative to patient-care technicians, who are unlicensed and, typically, lower paid.

Update (12/9): DCI did not comment on specific findings but released a statement from founder and board Chairman Dr. H. Keith Johnson saying the chain's "non-profit status allows us to devote a larger proportion of our resources to improving the care we offer to our patients."

Update (12/10): Fresenius spokeswoman Jane A. Kramer today issued the following statement:

"From the study's title, the methods-- all the way to the concluding statements, the authors loosely used the terms chain-affiliation, profit status, and chain size, three separate dimensions, and disingenuously intermingled them to reveal a strong pre-analytic bias. The authors themselves state that selection bias is 'likely to exist.' These data are over 5-7 years old – the environment has changed, with new scientific discoveries and clinical practice changes in place. It's difficult to imagine the utility or applicability of such a study."

Peter Laird, MD

Dec. 9, 2010, 6:15 p.m.

The entire issue of for profit medicine has troubled me for quite some time.  I have fortunately worked in both government positions as a physician and with Kaiser, one of the largest non-profit health care providers and I have seen the benefits given directly to the patient. The article by Yi Zhang, et al underscores the need to reevaluate our health care priorities in this country. We simply haven’t learned from the experiences of other nations who keep all of their health industry non-profit to the benefit of their population. It is time we consider this in America as a part of true health care reform.

Nice to see this confirming the New England Journal article of some years back.  I’ve also read negative press about for-profit nursing homes and hospitals.

Shouldn’t be surprised to find these for-profits find it more important to dance for investors and meet next quarter’s numbers, than worry about patient care.

INVESTIGATE UNOS…

I’d like to see an extensive report on UNOS (United Network for Organ Sharing), the private contractor tasked with the National Wait List for individuals needing an organ for transplantation.  They are wholly dependent on apparent altruistic donations, fully utilizing the ‘protection’ of federal law to maintain their failed system of organ donation.

Since 2005, when the wait list was in the high 80 thousands, I have watched the wait list grow to 110,100 (tonight).  What a shame when there is a SOLUTION readily available which UNOS refuses to adopt.  A small but feisty group called donate-for-life.com found the solution and had a well-known Fortune 100 insurance corporation conduct an actuarial analysis on the program.  Their conclusion: “It’ll Work!”  22 individuals die every day they hesitate.

A pilot program was recently offered to UNOS, but they, as always, go totally silent—when you’re protected by Uncle Sam, why worry?

Christopher Blagg

Dec. 10, 2010, 1:06 a.m.

This only confirms the feelings about for-profit dialysis expressed by Dr. Scribner some 30 or so years ago at a Congressional hearing and on a “60 Minutes” boadcast. More recently, in 2002 he described the typical U.S.patients on short three times a week dialysis as being “sickly, malnourished and hypertensive”
Despite the statement in the article that in 2004 all facilities appeared to have “high dialysis doses” the fact remains that episodes of blood pressure crashes during dialysis and feelings after dialysis of being “washed out” for the rest of the day are frequent enough to be regarded as normal by many patients and nephrologists.We have known for many years that home dialysis and more dialysis is better, whether more frequent or longer.
Still, as some politicians like to remind us, we in the U.S, are fortunate to have the best health care system in the world even though it is also the most expensive..

When profit is at the top of your agenda, the patient will always suffer.  When dialysis facilitites begin to put patients first, then everything else will fall into line, including profitability.

Dialysis units that put their patients first, have lower morbidity and mortality, as well as lower infection rates and admissions.

However, there is one other ugly little secret about for-profit chains, which is lower referal for transplantation.  Why?  Because they lose revenue.  Therefore, there if foot dragging going on during the education and preparation for referral to transplant centers.  Sometimes, this process is dragged out until the patient’s private insurance becomes secondary, which is certainly not fair to the patient.

As for mortality rates, corporate chains need to realize that you can’t dialyze the dead.  Therefore, failure to put the patient first is a poor business model.  It tells you that as smart as the leaders are of those various corporations, they’re not that smart.  Otherwise, they’d change the way they’re doing business with ESRD patients.

GorDuck, I agree that UNOS’ tract record may not be all that and a bag of chips.  However, donate for life has no track record.  I believe that things that appear too good to be true, often are.  The web site is not clear on exactly how the system works.  To me, it’s something in the start-up phase that has a long way to go.  I’ll be watching.

Dennis Cotter

Dec. 10, 2010, 9:16 a.m.

Dr. Zhang’s paper is the second in a series of MTPPI studies on dialysis chains.  In our next study, we will focus on the effects of bundling ESRD payments on treatment process and outcome changes. There is great interest in understanding how this new reimbursement policy will effect dialysis practices. We are open to suggestions on how best to measure these changes.

I am a dialysis patient. I have been on all kinds of treatments. Parentenal, in center and now NextStage home hemo. NextStage home hemo is by far the best theraphy. I go to the gym 5 days a week, travel in my RV, raise chickens and plant a garden. I also have had a liver and kidney transplant. Since starting the NextStage home hemo program I have had only a couple of short hospital stays for unrelated issues. My life has been transformed and I am the healthiest I have been in 15 years since transplant. Why isn’t the NextStage home hemo program expanded? Life is now good again!

JOE ATKINS…

Good, Joe, watch.  On the website is the name of that insurance corporation—look, you’ll find it along with my eMail.  When we have our patrons, board members and trustees, they’re ready with a pending grant.  All have access to our white paper and powerpoint presentations.  Your move.

The for-profits typically run three hemodialysis shifts a day, three hours in the chair for each patient, and they will be minimally staffed (just enough to comply with CMS health and safety regulations).  These companies have to answer to stock and bond holders and that drives their behavior.  When we were drafting new health and safety regulations in this area of the Medicare program between 2001-2005 the mortality differences between for-profits and not-for-profits were well known within CMS, but there was no statistical basis or studies that could be used as a basis to impose mandatory minimal staffing requirements nationwide.  The most likely response to this excellent article will come from the ESRD Network Forum, an industry appendage, that will question the methodology of the study, the size of the sample, and the timing of the data collection.

Thanks Max for your comment. We are certainly open to the ESRD Network Forum and other industry group suggestions on how to improve our analysis and expand the data source to embrace other factors not included in the Medicare/USRDS data that we use.

Thank you for this eye opening article. Very well written on a subject patients desperately need support and our help in.

arlene mullin-lane

Dec. 10, 2010, 12:42 p.m.

I am glad to see this finally in print. It appears that more is needing to come out. Not only care, but patient dismissals.

I have advocated for thousands of patients in being dismissed. CMS ,ESRD Networks were aware and never lifted a finger. Hopefully this will come out in Robins future articles.

Davita is number 1 in dismissals. Has been cited for one illegal dismissal..Cms did nothing. Plenty of emails to support this and documents. Voluntary information and ESRD Networks who have worked for the clinics. They vote themselves in. They need to go. Have plenty of denial letters to patients over the years. We need to have non-industry oversight.

It has to be brought to the surface once and for all.

One thing that needs to be looked at, is “adjusted mortality”.  The main word is “adjusted.”  As I’ve stated in previous posts at ProPublica, “mortality” has been adjusted and measured in such a way that true mortality of a facility isn’t being made public.

Just like our recent financial troubles in US banking and business has been fooled with creative accounty, so has the public been fooled by creative math that has been used to calculate mortality amoung ESRD providers.  If you’re really slick and know how to manipulate the numbers, you can make them say just about anything you want.

This is really frightening, because, even with the creative math, mortality in the US is pitiful.  Imagine what it would look like without the creative math.

GorDuck - Georgetown University hospital has a fantastic living donor program! They recently did a huge “chain” donation. It may be slow to catch on, but people are doing it.

My family got lucky - I happened to be an almost perfect match for my hubby (yes, that is very rare). He never had to do dialysis. After reading this, I’m even more grateful.

This article doesn’t mention what the causes of death are. Were they complications of dialysis or some other reason?

STACY…

Thanks for sharing.

The real benefit of donate-for-life.com is that within 48 months it literally empties the wait list to zero.  Too good to be true—no, not really, just gets the darn roadblocks, like UNOS, out of the way.  They’re protected by the government—can be very snarly when you step on their tail.

Can you imagine no wait list?  The other benefits are saving the taxpayers $24 billion or more during those 48 months from startup.  Or ending the black market in illicit organ procurement/sales worldwide.

What do you expect?
You get what you pay for!!
If the government is paying pennies for dialysis and every non profit major medical center or university medical center in the country could not afford to maintain its dialysis unit and ends up selling it to one of the major chains, then its a matter of time till the non profit chains will be swallowed by the big chains.
This is economics 101

There’s an interesting story, which involves a CMS representative named Brady Augustine.  During one meeting of the National Renal Administrators Association, probably back in 2003 or 2004, Mr. Augustine made the following statement to the audience during his talk (paraphrase) “over the next five years, I expect to see only half of you here.”  The insinuation was that he expected many of the independent operators to be bought out by the larger chains.  Needless to say, his statement planted a seed of fear in the minds of renal adminstrators,  In fact, Mr. Augustine went on, during his talk, telling the audience how the Department of Defense had narrowed down the field of military contractors from the Military industrial complex and that he expected that CMS would be doing the same with dialysis providers.  I wonder who paid his to make this comparrison?  Needless to say, his words generated allot of fear among independent providers, causing many of them to consider selling out to larger providers.  It was a stupid comparrison, as CMS really doesn’t contract out anything with dialysis providers.  Here, again, when you have powerful lobbying organizations in Washington and huge political donations at stake, you can manipulate your companies market position in an entire industry.  As for independents, they can still provide excellent care and make a profit.  It will not be as large of a profit as the large chains, but it can be done.  I do allot of consulting and there are nephrologist, who are beginning to realize that they were too hasty in selling their facilities.  The downfall of most nephrologist is the failure to hook up with a true business person who has the ability to efficienty manage his/her office practice, as well as dialysis unit.  Many nephrologists hook up with nurses or technicians they’ve worked with and befriended.  Unfortunately, these people are sincere, but not fiscally capable of managing a business.  The fact is that nephrologist need to take back control of their specialty and their industry.  My guess is that nephrologist will stumble along with the chains, for awhile.  But, sooner, or later, they will become frustrated, realizing that the patient-physician relationship has been usurped by money grubbing monsters, who could really care less about the wellness of their patients.  The worm will turn.

Gor - Well, I have a vested interest in the whole process! I share every single chance I get about living organ donations. I have other family members who are at high risk. Genetic kidney disease.

I know from speaking with people who’ve undergone dialysis that dialysis itself isn’t the hard part - it’s managing the side effects that is the hard part. My understanding is there is little in the way of preparing patients for the reality of how hard dialysis is. At some point, they become discouraged and stop doing what they should be doing to make the proceedure most effective. There’s little to no research on those who literally commit suicide by just quiting dialysis.

I’m not sure that it is fair to lay the blame at the facility’s feet - I suspect that we’d see mortality rates drop if we focused on education and support for the people who must undergo dialysis. Especially for those at highest risk with minimal family (or other) support systems in place. Compliment that with increased awareness of living organ donation - creating shorter wait times we’ll have fewer people on dialysis.

Granted, that would not be good news for the big chains and that will make it a much more difficult task.

Christy Price Rabetoy

Dec. 12, 2010, 12:40 p.m.

This article and the previous one truly outline the problems and realities of ESRD care in the US. For only a few short years after 1972 the Medicare program worked, but since then is has been little more than filled with controversey and lack of quality of care.  In my opinion there are three main reasons for the program results and care that exists today.  First, there were no “chains” in 1972 - it was health care, not the business of dialysis. Second, there were few dialysis technicians in 1972, now nephrology nurses are practically nonexistent in direct patient care - technicians, who until recently did not even require any dialysis or patient care competency credential, provide most, if not all, patient incenter treatments. Home therapies still require direct registered nurse patient care. Finally, in 1972 patients were evaluated as to the benefit they might receive from dialysis and their ability and desire to participate with the treatment regimen - now it is any breathing body, regardless of benefit of this extremely expensive therapy.  The Medicare ESRD program still stands as the failed model of universal predominately government paid care, and a sound rationale for never having another single payer health care program in the US.  We just do not know how to control the inherent domineering forces.

Roberta Mikles

Dec. 12, 2010, 4:01 p.m.

And, to think, some at the govenment level want more facility self-monitoring. This is even scarier

Roberta Mikles
http://www.qualitysafepatientcare.com

Christy - I was with you until you declared the Medicare ESRD program a failure and a reason to abandon any government sponsored health care.  The program is not a failure; it is a well-intentioned and necessary effort that is paralyzed by politics, greed, and public ignorance, and I applaud ProPublica for taking this on.  Personally, I think two ways to improve the quality of care by the chains is to mandate annual health and safety inspections by the state agencies and impose mandatory minimum staffing requirements.  Annual inspections along with monetary penalties (the current nursing home requirement) should be mandatory to protect this vulnerable patient population.  CMS should contract with Johns Hopkins, RAND, or any company that can provide the agency with a scientific basis to impose minimum staffing requirements for every dialysis facility.  There are other ways to improve the program that would not require legislation or studies, e.g., requiring that Epogen be administered subcutaneously as it is in other developed countries (this would save Medicare $500 million a year).  CMS also needs to look at national health care systems in developed nations that have much lower death rates then the U.S. and adopt any cost-effective practices that work. ESRD is a death sentence, and the only disease specifically covered by Medicare. The program can work here because it works in other nations.  They have the political will to protect their citizens and we allow corporate profits to trump public safety.  We need to be candid about why this isn’t working here and work to change the law.

Roberta Mikles

Dec. 12, 2010, 5:30 p.m.

Max, I, as others (and yourself) are very familiar with the lack of oversight of dilaysis facilities. CMS blames the states for not inspecting timely, the states blame CMS for not giving enough money to inspect, and the pt is caught in the middle.

Providers have lobbied to get their “NEW” units opened timely but you will never hear a provider lobby to get their EXISTING facilities inspected timely…
Roberta Mikles
http://www.qualitysafepatientcare.com

Roberta - When I worked in the enforcement area of CMS (then HCFA) the real problem was (and still is) nursing homes which must be inspected every 15 months by statute and I believe there are about 17,000 of them.  This devours almost all of the survery and certification budget and staff time leaving virtually nothing for approximately 22 other Medicare provider and supplier categories, including nonaccredited hospitals, community mental health centers, dialysis facilities, etc.  The agency has never been properly staffed or funded to do anything but inspect nursing homes and approximately 85% of the expertise of state agency nurse surveryors is in nursing homes.  That’s the source of the funding problem so the states have a legitimate complaint.  What we need is a statutory change requiring dialysis facilities to be inspected with the same frequency as nursing homes and also civil monetary penalties for serious noncompliance.  If it’s in the law, then they have to allocate the funds to do inspections.  There was a study by the Lewin Group around 1997 regarding the issue of having private accreditation bodies like JCAHO do ESRD surveys.  The argument at the time was, “Well it’s better then nothing at all”.  Many of us familiar with JCAHO hospital accreditation inspections were not enthusiastic about entrusting the health and safety of dialysis patients to an accrediting body working with for-profit dialysis companies.  In their report Lewin declined to endorse accreditation but did argue both sides of the issue (By the way, Lewin has since been purchased by one of the large for-profit insurance companies).

Roberta Mikles

Dec. 13, 2010, 11:04 a.m.

Max, I tried to get many, including dialysis organizations, etc., to provide patients with information re ‘bundling’ – when the proposed rule was open for public comment. To my knowledge, most, if not all, facilities did not provide written information on the bundling in order to give patients/families a change to respond to that which would, or could affect their care. I believed, and voiced such, that the Networks could send a one page FAQ to the units, the units could make one copy for each patient/family, with referral phone numbers, etc in case there were more questions. Patients have a right to know about anything that is proposed that might affect them, again. Now, I am getting calls from not only patients but staff regarding education of patients r/t bundling. So, let’s just continue to leave the patient out of everything, including that which might financially restrict many. Just like home dialysis. As soon as bundling came into effect, our unit, for example, had posters all over the lobby, like wall paper, pushing home. Max, I would welcome the opportunity to communicate with you, or anyone else, personally regarding various concerns.
Roberta Mikles - Dialysis Patient Advocate
http://www.qualitysafepatientcare.com

If any of us walked into our primary physician’s office and he/she discovered that we’d suddenly lost 50% of our renal function, they would become alarmed, sending us directly to a nephololgist for follow-up and testing.  Yet, when we take a kidney from a living donor, this is exactly what we are doing, we are, in one feld swoop, removing 50% of that person’s renal function.
The fact is that as we age, our kidney function slowly deteriorates every year we live.  We begin, at the age of 20 years, with 100% and by the time we are 70, we might only have 30%.  However, that gets us through our old age.
There is a reason why we have two kidneys, which is to provide a cusion of safety for traumatic injury, hypertension, diabetes, or any other number of things that we may incur or experience throughout our lives, that could negatively affect our renal function.  It’s because of this fact that taking the kidney of a living donor is not a good idea.
Although it’s not well publicized, there are incidents where living donors have had post dononation complications, ranging from chronic pain, all the way up to acquiring end stage renal disease themselves, causing them to need dialysis.  There are many documented incidents where brothers or sisters have donated a kidney to a sibling, only to wind up needing a donated kidney, later, themselves.
The entire concept of living donation is base on the concept of wrecking a good house, in order to fix a house that is broken.
If you take a kidney from a cadaver and, for some reason, the kidney does not work, it’s unfortunate, but not the end of the world.  However, if you take a kidney from a living donor, and it fails, that is a tradgety.  We must realize that a kidney transplant is not a cure, but only an alternative treatment for end stage renal disease.  The media is constantly portraying dialysis as a torturous machine that causes endless pain and death, when nothing could be further from the truth.  Actually, dialysis saves lives and it has been doing so for 50 years.  In fact, patients who choose daily home hemodialysis have the best level of wellness, nearly on par with a transplant and they don’t have to suppress thier immune system.
The Hippocratic Oath asks physicians “to do no harm.”  It’s the prime directive of all physicians.  However, when you remove 50% of a patients renal function, you are doing harm to them.  You may not see that harm, immediately, but it’s there.
The only reason that living donation is being pushed so hard, is due to the companies who make immunosuppressive drugs and transplant centers paid to do the procedure.  The fact is that cadaver donations are down and they need a fresh supply of body parts and they really don’t care where those parts come from.  The goal is to get the parts, so they can perform transplants and drug companies can sell drugs, period.  There is nothing noble about removing a kidney from a healthy patient.
The media is constantly bombarding the public with the notion that, by donating a kidney, you are saving a life.  Well, the bottom line is that the US Medicare ESRD program provides various forms of dialysis to save patient’s lives and it’s been doing so, successfully, since January of 1973.  It was the first of its kind of government program to treat a specific, life threatening disease.  It’s it perfect?  Most certainly not.  It needs improvement.  But, in spite of that, many, many lives have been saved, who, otherwise, would have been dead long ago.
For those of you who want to save a patient’s life, I urge you to donate blood.  Why?  Well, when you donate blood, you are litterally saving a life.  And, the best part about donating blood is that, unlike donating a kidney, blood replenishes itself, allowing you to donate and save lives, over and over, again.  Recently, I donated my 68th unit of blood and, according to the blood bank I donate to, without giving any specifics, they’ve informed me, many times, that I have, indeed, saved lives.

I don’t agree with you about living donations! I’ve seen how hard dialysis is on people and I’ve seen little kids in the transplant centers - little ones less than a year old! I spoke with a lady this morning who was waiting for her husband as he got his blood drawn - she shared with me how happy they were to learn that they may have a living donor!

My kidney function was 138% prior to donating my kidney - one month after donation I was again over 100%. BTW - I’m over 40 so it’s not because I am young. One kidney is more than sufficient. Kidney donars (on the whole) have a longer life span. Yes, I am sure there are some unfortunate complications for some people. And, that is tragic. However, the transplant center makes it very clear that while it is unlikely, complications can occur and they do include death. But so can childbirth.

If any of us walked into our primary physician’s office and he/she discovered that we’d suddenly lost 50% of our renal function, they would become alarmed, sending us directly to a nephologist for follow-up and testing.  Yet, when we take a kidney from a living donor, this is exactly what we are doing; we are, in one felt swoop, removing 50% of that person’s renal function.
The fact is that as we age, our kidney function slowly deteriorates every year.  We begin, at the age of 20 years, with 100% and by the time we are 70, we might only have 30%.  However, that gets us through our old age.
There is a reason why we have two kidneys, which is to provide a cushion of safety for traumatic injury, hypertension, diabetes, or any other number of things that we may incur or experience throughout our lives that could negatively affect our renal function.  It’s because of this fact that taking the kidney of a living donor is not a good idea.
Although it’s not well publicized, there are incidents where living donors have had post donation complications, ranging from chronic pain, all the way up to acquiring end stage renal disease themselves, causing them to need dialysis.  There are many documented incidents where brothers or sisters have donated a kidney, only to wind up needing a donated kidney, later, themselves.
The entire concept of living donation is base on the concept of wrecking a good house, in order to fix a house that is broken.
If you take a kidney from a cadaver and, for some reason, the kidney does not work; it’s unfortunate, but not the end of the world.  However, if you take a kidney from a living donor, and it fails, that is a tragedy.  We must realize that a kidney transplant is not a cure, but only an alternative treatment for end stage renal disease.  The media is constantly portraying dialysis as a torturous machine that causes endless pain and death, when nothing could be further from the truth.  Actually, dialysis saves lives and it has been doing so for 50 years.  In fact, patients who choose daily home hemodialysis have the best level of wellness, nearly on par with a transplant and they don’t have to suppress their immune system.
The Hippocratic Oath asks physicians “to do no harm.”  It’s the prime directive of all physicians.  However, when you remove 50% of a patient’s renal function, you are doing harm to them.  You may not see that harm, immediately, but it’s there.
The only reason that living donation is being pushed so hard is due to the companies who make immunosuppressive drugs and transplant centers.  The fact is that cadaver donations are down and they need a fresh supply of body parts and they really don’t care where those parts come from.  The goal is to get the parts, so they can transplant and sell drugs, period.  There is nothing noble about removing a kidney from a healthy patient.
The media is constantly bombarding the public with the notion that, by donating a kidney, you are saving a life.  Well, the bottom line is that the US Medicare ESRD program provides various forms of dialysis to save patient’s lives and it’s been doing so since January of 1973.
For those of you who want to save a patient’s life, I urge you to donate blood.  Why?  Well, when you donate blood, you are literally saving a life.  And, the best part about donating blood is that, unlike donating a kidney, blood replenishes itself.

Stacy,

I’m not saying that a person can’t “get by” with one kidney.  Some people only have one kidney to begin with, for various and sundry reasons.  However, just because a person can “get by” with one kidney doesn’t justify taking a kidney from a healthy person.

The concept that is implied by the transplant industrial complex and the media, is that “well, you have two kidneys and really don’t need both of them, so why not donate it” treating your “spare kidney” like an un-needed old spare tire.”  By the way, who in their right mind would go on a long trip, without a spare?

Let’s be clear.  No concrete, unbiased studies, have been done that has proven, without any doubt, that there are not negative consequences to living kidney donation.  The media has made this an emotional issue and have done everything they can to skirt around the pregmatic science of what happens to a person, in the long and short run, when they lose 50% of their renal function.

Am I totally against living kidney donation?  No.  If one of my sons needed a kidney, I’d donate in a heartbeat, without any reservation, because it would be going to my child.  I’m sure that the majority of parents feel that way.  However, I would not take a kidney from either of my children, nor would I take a kidney from any other living donor, because I wouldn’t want to be responsible for any untoward complication(s) that might occur to them, in the future.

Here’s another eithical dilemma, which is, after living donors donate a kidney, they are forgotten.  A few transplant centers will do follow-up for a year after the transplant, but, afterward, the donor is on their own.  If they do have a problem, tough crap.  They are told “well, if you ever need a kidney, we’ll push you up to the top of the list.”  After donors have had their fifteen minutes of a ‘feel good” moment, then, it’s reality time.  Everybody has gotten what they wanted and they don’t need you, anymore.

Everyone talking a living donor out of a kidney stands to gain something, except the donor.  The patient gets a new kidney, the transplant team and hospital get their money, the drug company gets another person dependent upon their immunosuppressive drugs and make money, but the donor gets nothing, but an “attaboy.”

One thing that I find nausiating is how the media portrays dialysis as “a living death.”  How soon we forget that before the availability of dialysis, people simply died.  Now, the USA has hundreds of thousands of people, living life via the benefit of dialysis services.

One solution to the need for transplantable kidneys is to promote cadaver donation.  Millions of good organs are buried, every year, simply because people haven’t been properly educated about the benefits of cadaver donation.  Somewhere along the line, we Americans have decided to insulate oureselves from death.  We can’t face it.  We want to live, forever and we expect our medical science to make that happen.  But, the sad truth is that we are mortal.  When we die, we no longer need our organs.  If we can be made to understand that, donating kidneys upon our death would become a natural fact of life.  That is the best, most ethical and moral solution for meeting the needs of transplantable organs.

guenstig uebernachtung in frankfurt buchen

Dec. 14, 2010, 2:24 p.m.

Railway Freedom,coffee milk egg media respect would structure cell executive organise floor spread see system secretary sense cultural wild other forward round mean since occasion percent top tape letter get next join other prefer clearly benefit package table introduce society sell destroy incident hot right effectively up practical highly carry on attract bad from ordinary noise panel around tree whilst drive wife wine rest weekend via better sense wave regard expensive victory black wood launch proposal crime until event nice might sound membership sound resource arrange

More and more hospitals are “forced” or “coerced” into selling their inpatient and outpatient dialysis facilities. The government is allowing a monopoly to occur because of the “cost cutting” techniques and promises that the larger chains make. These chains have had much to do with the new Conditions of Coverage…promising outcomes…data….supplies & equipment and intensive quality improvement activities that no other area of medicine is asked to provide….with the promise of improved eficiency at the cost of large staffing ratios. It is difficult providing and planning patient care…now a thesis is required. I have been in the field of dialysis for over 30 years. What is happening now is appalling.

Stacy,
Please look at the following web site from livingdonorsonline.org, which states the following:

“A2: What are the long-term effects on me if I donate one of my kidneys?
Frankly, there is inadequate medical research on the long-term consequences of living donation, and some of the research available is limited in scope (e.g., one transplant center) or does not follow statistically rigorous procedures (e.g., inadequate sampling). The research currently available has shown there are few, if any, long-term effects on a living kidney donor. Mortality rates look to be the same or better than the general population. Some studies have revealed slightly higher incidence of high blood pressure and elevated levels of protein in the urine. There is also a possibility (0.1% to 1.1%) that a living kidney donor will develop End Stage Renal Disease and need a kidney transplant. This page describes the research results more completely. However, much more rigorous research is needed to answer this question with confidence.”

Clearly, telling people that there are little to no consequence for living kidney donation do not have any idea of what they are talking about.  Everything that plops out of their mouths is, for lack of better words, made up.  It’s a concept that runs more on emotionalism, trying to strike a cord of sympathy in the living donor, without the benefit of the truth.

In order for a person to consent to any procedure, they need to be made, clearly, aware of the consequences of their actions.  This is not happening, as transplant centers, kidney organizations and drug companies, as well as the patient in need, have a vested interest in having an uneducated living donor, willing to give up any body part.  The message to living donors is this “you have two kidneys, and if you’re not willing to share one, you are selfish and uncaring.”  It’s a marketing program, not an educational program.  And, it’s most certainly not providing potential living donors with informed concent.

I’m frankly a little apalled at a previous comment that insinuated that patients at for-profit dialysis centers are not referring patients to transplant because they don’t want to lose money.  I have no idea what the reason for the discrepancy, but I can assure you that, at least in the area I work, that is far from the case.

I work in a for profit company as a social worker, and have for almost a decade.  I have never been told, officially or unofficially, that I should hold off on referring a patient or a group of patients for transplant.  And, frankly, I don’t know of any social worker that would agree to that.  Even if we did, the patient would only need to speak to their MD to get the referral, instead.  Indeed, from the very beginning of the time I’ve worked in dialysis, I’ve known that CMS requires that we be able to show that the patient was offered transplant as an option and what we have done to follow-up on that.

Today, I got the news that a patient at our clinic is transplanting.  I am thrilled, as are all of the other folks who work here.  We celebrate transplants as victories because we know how hard it is for our patients to go through what they do every day.

From most of the comments that I’ve seen in relation to these articles, I’ve noted that the people who work in dialysis, especially those who work for for-profits, seem to be painted with a broad-brush, as some kind of stoolies for the company we work for…that kind of dichotomous thinking just does not work and is never helpful when trying to solve systemic problems.  I have to wonder, if the comments hadn’t been so negative, if more people who work in dialysis might have responded and been willing to share their own ideas about creating solutions to problems within the industry.

Roberta Mikles

Dec. 15, 2010, 8:32 p.m.

It would be nice to hear solutions to problems as I have tried to present ways to improve delivery of care, involve the patient and prevent errors from happening…. most to deaf ear. It is about all working together, but, in my opinion, many facilities see it as ‘we against you’ instead of ‘us working together’.
I also respect those posting who do not want to give their real name and wonder why someone would not want to do such. Indeed, posting in an anonymous way gives one permission to state perhaps that which they would not if they gave their name. I also notice that propublic made mention of giving real names. But, again, I appreciate the situation many might be in and not want to give their real names.
Roberta Mikles RN
http://www.qualitysafepatientcare.com

Roberta…I am only one person and not many, and I did not give my real name because it doesn’t feel safe to do so.  And not because I’m worried about my company, but because none of what I’ve read in the comments or even in the articles feels like it respects the fact that there are a lot of professionals out in the clinics who are doing their best (and this is in both for profit and non-profits).

Your sense of “we against you” may come from the sheer lack of support that clinics may feel.  Most dialysis companies have what I would call a “franchise” model.  The clinic manager is responsible for running “their” business…the one major difference is that they are given a tight budget from the upper management with little room to spare.  The clinic’s develop a sense of being out there on their own (even if this is not supported by the larger company’s message).  It creates a culture of deprivation…you may intellectually understand that there is money to spare, but at your clinic level it just does not exist, and clinic manager’s have very little power to effect that.

When people feel overwhelmed, when they are asked to do a lot with too little, you are right that they become defensive.  I’ve seen it happen over and over.  But I’ve also seen that approaching staff with the attitude that conveys respect and cooperation, actually can make change happen.  But the reality is that larger change has to come from the top, changing the system that locks people into reactive positions.  I have to admit that about that I am somewhat more cynical given that corporations are legally bound to protect the interests of shareholders first, and am a firm believer in general in public, not private, provision of healthcare.

Roberta Mikles

Dec. 16, 2010, 9:56 a.m.

CALCSW, I respect that which you state.  I believe much of the problems that patients experience in units is the result of a lack of appropriate unit level supervision which includes management being adequately trained themself in order to oversee practices implemented by staff. Without adequate supervision there is no foundation ... I have seen, over and over, where there is lack of supervision and this is greatly evidenced in survey findings. This is even more supportive of having patients be fully educated in order to work as a team with staff in order to prevent errors and ensure correct practices are implemented. However, many units have such a culture that puts patients at the mercy of staff which includes reprisal in varying degrees when patients/families bring forth incorrect practices. Often, physicians not being in the unit all the time are not aware of such and ‘take the side of staff ’ as this is a tight, cohesive culture that lies within the units
Roberta Mikles
http://www.qualitysafepatientcare.com

Roberta Mikles

Dec. 16, 2010, 10:10 a.m.

please know that all my comments are based on my opinions, or my ongoing communications with patients, families and healthcare professionals, along with review of survey findings. I have for six years, been involved in the aforementioned and have attempted, at various levels to effect change. Not all units provide substandard care. Many units have staff that are kind, attentive to their responsibilities, etc, and then there are those that are not. This is why it is so important for staff to understand what the patient experiences as this lifestyle changes e.g. physicially, emotionally, etc.
Roberta Mikles
http://www.qualitysafepatientcare.com

I work at Davita and it is a wonderful company who takes great pride in caring for it’s stormed. We have strict policies and procedures that they are always one step ahead of the rest of the non profit unit I used to work at! They keep me educated and make sure I educate my patients. I am resided to meet goals with my patients labs and if I don’t I have to reevaluate and report a new plan of care to my leader. I am an RN running a home hemo program and in 3 years we have grown to a successful 20 patient program and seen patents go back to working full time. You can’t go by old data. We have made great strides in the last few years and are proud of our company!
Joy

I am a 18yr. certified hemodialysis technician who has worked at non profit clinics and the large for profit clinics and there is one difference between them and how they run. Patient to staff ratio. For profit clinics have stretched the floor workers so far it is all but impossible to do the patient care. Their excuse is the new CMS regulations but the CMS doesn’t dictate the ratio,the companies do.What it comes down to is the almighty dollar and healthcare pays the price with lives.

As a caregiver to a patient who received treatment at a for profit in-center dialysis center, I witnessed great disparity from the physician, social worker, nutritionist and technicians while they cared for the patients.  One particular physician would not speak to his patients other than to ask if they needed medications or if they were interested in the football team he likened. He even had the audasity as to walk out of a meeting with a patient and their caregiver.  The patients at this treatment center are treated as cattle; line them up, stick them, and get them out for the next group so we can go home.  No compassion, no education, and no encouragement when one is doing well or needs help to continue on.  One ptient even talked about stopping treatment and ending his life to the social worker who responded as to say, “don’t you have a therapist you can talk to?”  Obviously this was out of her expertise. 
Where do they find these people?
Why are they in this field of health care when they truly do not care?

What I am trying to stress is that for- profit centers are all about the money; Not the patint.

If anyone knows of an in-center where one can truly find compassionate care in Md. where the nephrologist respects the opinion and knowledge from the patient about their body and how it responds of does not respond to certain medications or treatments,  please advise.

I am an advocate for other ESRD patients looking for the BEST CARE where we are respected as people who are intelligent, who work hard every day to live life at its best and who want to surround themselves with positive health care providers and patients.
It’s time we let others know about the dirty laundry of kidney health care.
We did not ask for this disease but we can make sure others know of the injustices we’ve faced.
lambchop

I believe that every person working in dialysis wants to care about the patients and they want to do a good job.  However, when staff are overwhelmed with too many patients to care for a one time, accidents are going to happen.
The only time that operators of dialysis chains really care about what’s going on in the trenches is when a catastrophic event brings negative attention to the organization.  Then, all of a sudden, there is great concern and so and so is going to do something about it.  “Accident’s happen and we really care about the quality of care our patients receive.  Our goal is to provide the best care.”
If these people cared more about the quality of their care, as opposed to the bottom line, they wouldn’t be apologizing all the time.  There’d be no reasons for “We’re sorry.”  Well, they’re sorry, alright.  Sorry they got caught with their pants down around their ankles, providing piss poor care.
The key for these organizations is to put quality first, for if they do, profit will follow.  Good business means providing a good product.  The product we provide is dialysis.  If we do it well, patients will thrive.  If patients thrive and have a better level of wellness, that reflects well upon the provider of care.  Doesn’t it make sense that it would be better to be praised for excellent care than to be damn for providing poor, or mediocre care?
I’ve been in this business for going on 38 years and I’m proud of the care I’ve provided over those years.  It makes me sick to see how the industry has deteriorated over those many years.  There was a time when the patient did come first.  That was before our field was hyjacked by the money changers.  There is a difference between running a dialysis unit efficiently and running it to maximize profit, regardless of the negative effect your business model has on the quality of care.  We’re not talking about widgits, here, folks, we’re talking about human beings.
The problem that patients have, today, is the fact that their humanity is being taken away from them.  They have become numbers and no one is listening to their concerns.  This is why these articles have and are being written.  All is not well in the world of dialysis and it’s never going to improve if we don’t address it, now.  The Emperor is not completely unclothed, but he is wearing a distastful speedo.

If there’s any real question about the intentions of the large dialysis chains, toward their patients, just keep this in mind.  In order for a patient to be accepted into a large dialysis chain facility, they must first be cleared by the central billing office of the corporation.  Regardless of the need of the patient, there is no compassion at the top.  It’s all about the dollars and cents, first.
Let’s say a unit or even a regional manager of a dialysis chain would like to let the patient come in, simply for humanitarian reasons, it wouldn’t be allowed to happen.  Why?  Because central office doesn’t really care about that patient.  All they care about is the ability of the patient to pay.
As for the wonderful renal networks, the one thing they will allow a patient to be dumped for, or denied care for, is inability to pay, even the twenty percent.  Even a small percentage of the twenty percent.  In otherwords, they are like Scrooge.
While I’m at it, I’d like to address CALCSW.  CALC, if you’re working for a large chain, I’d bet you’re trying to care for a couple of hundred patients.  Afterall, that seems to be the going numbers for social workers, as I hear it at the NKF annual seminars.  I never hear one good word about patient to social worker ratios from MSW’s who work for the chains.  All I hear is “we don’t have time to talk with our patients.”  Many MSW’s simply try to look at patient labs to see who’s going down the toilet, to try and prioritize their time.  Well, CALC, that’s not providing good care.  That’s called looking out for the stock holders in order to maximize their profits and increase the price of the stock.  And, all of this is done at the expense of the patient, and your wits end.

This article is part of an ongoing investigation:
Dialysis

Dialysis: High Costs and Hidden Perils of a Treatment Guaranteed to All

Nearly 40 years after Congress created a unique entitlement for patients with kidney failure, U.S. death rates and per-patient costs are among the world's highest while the biggest for-profit providers flourish.

The Story So Far

Dialysis holds a special place in U.S. medicine. In the 1960’s, it was the nation’s signature example of rationing, an expensive miracle therapy available only to a lucky few. A decade later, when Congress created a special entitlement to pay for it, dialysis became the country’s most ambitious experiment in universal care.

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