What Gary Peterson said:
What people want most during emergencies is information. The Kidney Community Emergency Response (KCER) Program offers no centralized information to patients during emergencies, often leaving patients at the mercy of for-profit providers that hoard both information and patients. (Preparing for Emergencies: a Guide for People on Dialysis — June 2017 Update)
This is typical of how dialysis patient advocacy groups operate in the US. (Don’t bite the hands that feeds you, despite the fact that they are harming the patients for whom you are „advocates“.) There is no (for-profit) industry money for those groups that attack the junk-credit-rating business model which, compared to the non-profit business model, continues to cause the deaths of thousands of dialysis patients unnecessarily.
A few ago on a conference call, I heard Doug Johnson, the chief medical officer of non-profit DCI, state that his organization was not greatly motivated by the financial incentives of the QIP program. On the same call, a top nephrologist for one of the top for-profit dialysis providers said his organization was ‘jumping through all sorts of hoops’ for these financial incentives.
It seems these financial incentives make little difference to those already doing the right things for patients. These financial incentives also seem to motivate the for-profit companies to manipulate or massage QIP data, or even report fraudulent QIP data, resulting in a lack of congruence between USRDS mortality/hospitalization results and the CMS star rating system results.
This could explain why DaVita fought the implementation of the CMS star rating system, but then embraced it when the initial star ratings surprisingly showed that DaVita had the best results (while DCI has had the best mortality/hospitalization data for 14 consecutive years). This throws into question the integrity of all U.S. dialysis data collection systems.
53-minute YouTube video from September 2016 KidneyWorks meeting. Dr. Doug Johnson, chief medical officer (CMO) of DCI, speaks between 24:10 and 35:40.
Speaking on dialysis patient employment, he states:
„Honestly, we have not done a good job to make it more likely for you to be employed.“
Can you imagine the CMO of Fresenius or DaVita making such a statement? DCI has also had the best mortality and hospitalization data compared to Fresenius and DaVita for the last 14 years. DCI does the right things for patients because they do not have perverse financial incentives. The only way to make major changes in Fresenius’ and DaVita’s operations is to change their financial incentives.
How much longer will U.S. nephrologists continue to debilitate dialysis patients with short, brutish, minimal treatments, as well as ignore the iatrogenic effect that these treatments have on the social needs of their patients?
For me, the most symbolic moment in John Oliver’s exposé of what is wrong is U.S. dialysis care occurs around the 7:40 mark. DaVita’s Kent Thiry is leading a cheer and among those responding is the nephrologist who is the honorary historian for the American Association of Kidney Patients (AAKP). In a 2017 press release AAKP President Paul T. Conway stated, „Dr. (redacted) is a prolific and respected writer, and we are honored to have him tell the compelling history of how kidney patients have worked through the past several decades to impact treatment and chart the course for strategic patient engagement for themselves and all who suffer from a chronic disease.“
I believe the biggest point that John Oliver missed is how complicit U.S. nephrologists have been with junk-credit-rating companies in providing embarrassingly poor dialysis care. Hundreds of now prominent U.S. nephrologists have become multimillionaires from these business practices. Thousands of younger nephrologists are now financially dependent on this business model. Their incomes, their medical school loan payments, their children’s college funds, and their own retirement plans depend upon continuing these medically- and morally-poor business practices.
John Oliver could have also made these points:
Virtually all nephrologists would choose a different dialysis treatment modality for themselves than the one that the vast majority of their patients utilize
The largest non-profit dialysis provider has had better survival and hospitalization rates than the largest for-profit providers for 14 consecutive years
This field of medicine has abysmal employment and rehabilitation rates
Will U.S. nephrology continue ever be capable of any kind of effective self-examination? Will they listen to financially independent patient groups that don’t fawn over them for their supposed patient-centered care?
They say history is written by the winners. U.S. dialysis patients have not been the winners.
Both DaVita and Fresenius Medical Care have risen to the top in the U.S. through junk-bond-financed acquisitions of dialysis centers. This has put hundreds of millions of dollars into the pockets of leading U.S. nephrologists who, as partners and/or employees of these corporations, no longer effectively advocate for patients. In junk-bond corporations, physicians focus on numbers and metrics, not patients.
This story (link) is as much about the moral failure of corporate leadership as it is about the moral failure of many U.S. nephrologists and the enabling and facilitating positions of their professional organizations. They continue to shepherd over 85% of their patients into dialysis treatment regimens they would never accept for themselves or their own family members.
The U.S. dialysis care industry doesn’t need far better medical leadership, it needs far better moral leadership.
If this (link) isn’t a wake-up call for the American Society of Nephrology and the Renal Physicians Association to change, then they should forever be seen as organizations that foster physician and corporate greed. It shouldn’t be the case that John Oliver is a better patient advocate than the ASN and RPA.
President Donald Trump announced on May 4 that he will nominate a former DaVita executive as Assistant Secretary of Health and Human Services for Legislation. Matthew Bassett worked for DaVita from 2006 to 2011, and left the company as Vice President of State Public Policy.
Fresenius Medical Care’s credit rating has fluctuated between investment grade and junk grade over the last decade, depending on the rating agency (see 2015 article). DaVita’s credit rating has always been junk grade.
The large for-profit dialysis corporations have borrowed heavily to purchase thousands of dialysis clinics from U.S. nephrologists, making hundreds of leading U.S. nephrologists multi-millionaires. The chief medical officers of FMC and DaVita then have to practice medical with the pressure of billions of dollars of high-interest-rate, low-grade corporate debt on their shoulders. Servicing this debt and maintaining their stock price appears to lead to decisions that do not serve the patients’ best interests. For 14 years consecutive years, DCI, a non-profit, has had the best mortality and hospitalization rates in the industry.
Is there any better example of how poorly designed financial incentives in for-profit medicine can harm patients — than U.S. dialysis care?
If U.S. dialysis care is ever going to be „great again,“ it doesn’t need far better medical leadership, it needs far better moral leadership.
U.S. dialysis care should be the poster child of „conflicts of interest“ in U.S. medical care. The combination of physician ownership of dialysis facilities and corporate junk-bond financing of dialysis facility acquisitions has led to a decades-long failure of patient advocacy responsibilities by U.S. nephrology. The result has been ‘junk-bond nephrology.’ Most leading practitioners have greatly rewarded themselves financially while this field of medicine has lagged far behind others in improving patient outcomes and technology. “Dialysis is a promise unfulfilled,” said Jonathan Himmelfarb, director of the Kidney Research Institute.
Gary Peterson: Are there any better descriptions of the realities of for-profit U.S. dialysis care than the two below quotations?
(KevinMD blog): „Pay-for-performance takes medical quality metrics to the next level by using them economically. In our health care system, they are not working to improve care — why? Because the metric does not incentivize doctors to be more human. Instead, it rewards treating patients as commodities and lifeless objects. Doctors resent this incentive because commodification is dehumanizing. As incentives push doctors into becoming more mechanistic, we then invent new metrics such as “satisfaction surveys” to desperately attempt to pull them back towards a humanistic ideal. Satisfaction itself is now a commodity and subject to the rules of the market — massive, absurd inflation everywhere!“
„The art of medicine, whatever that might mean, is not measurable, and teeters on the verge of extinction. Increased control over the body ended up bringing about domination over bodies: paternalism, futile end-of-life care, polypharmacy … and pay-for-performance. Pay-for-performance promises the quantification of the entire patient-physician relationship and then its optimization as providers become rational profit-maximizers. Rather than the comforting hand of the healer, the invisible hand of the market will guide improved patient care. So goes progress.“
This is (yet) another wake-up message for patients and their advocates. U.S. nephrologists have little or no interest in disrupting their economic/treatment system with a well-patient model of care. With today’s financial incentives, most of U.S. nephrologists aim no higher than „not dead“ and „not in the hospital.“ This current system of care is likely a major factor in the widespread depression seen in dialysis patients. (Can you even raise this issue at an ASN or RPA meeting, let alone a FMC or DaVita meeting?)
Until we provide significant financial incentives to motivate nephrologists to deliver well, high-functioning patients, Kt/V (URR) and stagnant technology will remain the standards of excellence in U.S. dialysis care.
Why isn’t effective health coaching a standard of U.S. dialysis care? Blame the power of poorly-designed financial incentives, especially the perverse incentives that have made CEOs and many U.S. nephrologists multi-millionaires.
For the for-profit dialysis centers and nephrologists, their financial goals and incentives lead them to perform as little uncompensated care as possible for their patients. Most patients are steered into minimal, in-center dialysis regimens that virtually no dialysis professionals would choose for themselves.
The largest non-profit dialysis company, DCI, not only has the best mortality and hospitalizations data, but they also steer as many patients as possible to transplantation before they need dialysis.
It would seem that many dialysis patients could benefit from this „coaching at their fingertips,“ as long as it is not provided by for-profit companies under today’s perverse financial incentives.
„Employment and education status were inversely associated with mortality in patients on maintenance HD in Japan. Employment but not education was also inversely associated with hospitalizations. After adjustment for comorbidities, the associations with clinical outcomes tended to be stronger for employment than education status.“
There is no better example of excellence in dialysis care than an employed dialysis patient. It has been a tragedy that the leaders of the dialysis patient organizations have not made employment and rehabilitation leading priorities, as these goals can drive so many improvements in care processes, technology, and patient engagement. Instead, patients have endured decades of stagnancy and being ignored. Enduring awful treatment regimens, which U.S. nephrologists would never accept for themselves, has become the „job“ for too many patients.
U.S. dialysis care, which is effectively controlled by junk-bond-financed, for-profit corporations, is unnecessarily harming and killing thousands of dialysis patients each year. U.S. nephrologists would never accept for themselves the treatment regimens that the vast majority of their patients receive. Until U.S. nephrologists, the American Society of Nephrology, and the Renal Physicians Association break free from the financial ties and medical practice controls of these corporations, U.S. dialysis care will continue to be the prime example of medical materialism gone wrong… and the shame of U.S. medicine. Physicians cannot serve two masters.
How many more millions of dollars and precious time must we waste trying to create a quality measurement system that uses biochemical markers that do not matter to patients — or uses measures that can be „manufactured“ through manipulation and/or cheating?
The best example of excellence in dialysis care is a long-time employed ESRD patient. Unfortunately, CMS, U.S. nephrologists, and the large for-profit dialysis providers have ignored this outcome for decades. They have instead focused on biochemical markers, which has led to few improvements in the patients’ quality of life or technological innovations over the last 40 years.
While DaVita and Fresenius have recently announced programs to support employment, there is little to them beyond „turfing“ patients to government agencies that have no dialysis expertise. It seems to be a new version of the intern’s way to avoid addressing patients’ needs. Remember „buff and turf“ from The House of God?
What if Fresenius and DaVita employed dialysis patients and also paid their health insurance premiums? Extending the Medicare Secondary Payer (MSP) period for employed patients would then drive tremendous changes in this field of for-profit medicine.
It is time to admit that U.S. dialysis care has failed patients and instead functions primarily to serve the financial interests of for-profit corporations and the many prominent U.S. nephrologists who find no fault with the current economic incentives.
The Hippocratic Oath vs. medical materialism. The U.S. experiment in balancing medical decisions and profit motives does have its most spectacular failures.
It appears that our society’s most vulnerable patients (in nursing homes and dialysis clinics) are also the most susceptible to medical decisions that favor corporate owners over patient well-being. The weakest get used.
In U.S. dialysis care, the Peer Group and the American Society of Nephrology continue to be blind to the impact of financial incentives/structures on U.S. dialysis care. Has any other field of medicine made so little progress in the last 40 years? Does any other field of medicine have so many physicians admitting that they would choose better treatment regimens for themselves than they provide for vast majority of their patients?
Why has the largest non-profit dialysis provider (DCI) delivered better mortality and hospitalization outcomes than the largest for-profit, junk-bond-financed, dialysis providers for 13 years? Most U.S. nephrologists advocate for whom?
Our system is out of balance and, in many ways, self-defeating. Denial of the harmful effects of profit motives — and the legal implications of acknowledging the thousands of avoidable patient deaths — prevents any meaningful changes from occurring. As a result, most dialysis patients will continue to be shepherded into more harmful, for-profit, treatment regimens.
Other than „assisting“ a patient in choosing a dialysis modality (which may or may not be available locally), there seems to be little being done for patients regarding employment and rehabilitation.
Until these for-profit corporations have a financial incentive — rather than disincentives — to increase patient employment and rehabilitation, these „thrive“ programs will consist of little more than throwing information and hyperlinks at patients and saying, „Go for it.“
For working-age patients, this remains largely self-defeating and far from holistic dialysis care. Due to decades of paternalistic care and ineffective patient advocacy, the large for-profit corporations have neither the infrastructure, the technology, the professional expertise, nor the needed patient feedback mechanisms to drive significant improvements in employment and rehabilitation rates. Ratios of patients-to-social workers (and nurses) are far too high for any meaningful change to occur. As Dr. Scribner said, „If the treatment of chronic uremia cannot fully rehabilitate the patient, the treatment is inadequate.“
Without financial incentives for these corporations, only the patients with a strong will to overcome enormous obstacles — essentially on their own — will thrive. Almost all other patients will default to short-time, in-center, daytime treatments, and enslavement to a life called dialysis.
This situation will only truly change when these profit-focused companies can tell working-age patients, „It is financially advantageous for our company that you remain employed and/or get rehabilitated.“ Physicians and patients must fight for the holistic care that was the norm in dialysis care 45 years ago.
Fresenius and DaVita should employ dialysis patients. Then they would gain the expertise needed to truly help working-age patients.
More evidence suggesting that CMS and U.S. nephrologists have been harming dialysis patients for the last 40 years by failing to incorporate the patients’ employment and rehabilitation goals into the system of care.
This awful piece continues to overlook the failures and shortcomings of the stagnant and harmful model of U.S. dialysis care. This model functions primarily to maximize the benefits for junk-bond financed dialysis corporations which, in turn, fill the political campaign coffers of U.S. congresspeople.
Nearly all U.S. nephrologists have failed to target – or deliver – thriving dialysis patients for the last forty years. Considering the enormous, continuous, and rapid advancements in renal transplantation, it is time for the U.S. government to abandon dialysis care as a long-term treatment for most kidney failure patients.
U.S. dialysis care is effectively controlled by junk-bond-financed corporations which have little interest in greatly improving either their technology or the quality of their patients’ lives. While this junk-bond approach to medicine has richly rewarded many prominent U.S. nephrologists, it is hopelessly stagnant, is blind to the effects of its perverse financial incentives, and has failed patients and taxpayers for decades. All avenues that increase kidney transplantation rates – including payments to donors – need to be explored.
Only financial incentives and for-profit-corporation control of government policymaking explains why the US trails other first-world in countries in dialysis care.
US nephrologists continue to believe (and deny) that they can serve two masters without causing patient harm. Leading nephrologists in junk-bond-financed corporations ARE the biggest problem in US dialysis care.
In addition, it seems nearly all nephrologists – even the author of this blog posting – discount the importance of psychosocial needs in renal replacement therapies. They still do not ask, „What, besides medical needs, is important to the patient?“
Considering the recent breakthroughs in transplantation and the long-term stagnation seen in for-profit US dialysis care, I now believe the time for paying kidney donors has come.
It is time to rehabilitate and return as many of kidney disease patients as possible to living as normal lives as possible. US dialysis care nephrologists and CMS have failed to carry out the mission they were given by Congress over 40 years ago.
Long-term dialysis care has failed over 90% of patients. Continuing to keep patients on dialysis unnecessarily is uneconomical, is awful medicine, and continues to limit the meaning and purpose of far too many patients’ lives to being revenue streams for paying off junk bonds.
The Peer group appears to continue to be blind to the impact of financial incentives/structures on U.S. dialysis care. Can they not see the differences in mortality/hospitalization rates that have existed for over 15 years between the non-profit DCI and the for-profit, junk-bond-financed DaVita/FMC?
Unfortunately, all consensus statements by the Peer group must have the buy-ins of the chief medical officers of the two biggest for-profit, junk-bond-financed corporations. When will U.S. nephrology acknowledge the obvious conflicts of interest and finally cut these ties?
The Peer group also continues to fail to embrace the more holistic approach to dialysis care which was the norm fifty years ago. At that time, patients were part of the „team“ and the model of care included the psychosocial, technological, infrastructure, employment, rehabilitation, and quality-of-life needs of the patients.
The chief medical officer of Fresenius Medical Care again fails to mention dialysis patient employment or rehabilitation as a goal of overall care. He does advocate for:
„…tailoring dialysis prescriptions and schedules to current physiologic needs;“ (but apparently not for psychosocial needs).
These junk-bond-financed medical corporations need to extract maximum profits from existing infrastructure and capital investments. Their corporate officers have little interest in major breakthroughs that would destroy their business model. These corporate officers continue to fail chronic kidney disease patients and the U.S. taxpayers by failing to target patient rehabilitation and employment. Only a small percentage of patients being treated by these junk-bond corporations are able to avoid enslavement to a life called dialysis. On top of all this, according to more than a decade of USRDS data, these junk-bond corporations provide worse outcomes for their patients than the largest non-profit dialysis care corporation.
Until U.S. nephrologists and the American Society of Nephrology extricate themselves from the profit schemes of junk-bond medical corporations and instead become true patient advocates, U.S. dialysis patient care will continue to trail other first-world countries not only in mortality, but also in patients’ quality of life.
Dialysis patients need to wake up to the fact that junk-bond medical corporations have failed them… and will continue to fail them.
If CMS and U.S. nephrologists had targeted improving dialysis patient employment rates from the beginning, the ESCO concept would have been integrated into the system of care for decades.
Providing financial incentives to increase employment rates would:
improve patients’ medical care
drive technological advancements
improve care coordination
improve psychosocial support services
improve patients’ quality of life
create a more diverse dialysis infrastructure
drive more individualized, patient-centered care
What other target/incentive does this?
It’s not just about getting everyone to home dialysis therapies.
I believe we need to differentiate between non-profit dialysis centers and the for-profit, junk-credit-rating-corporation dialysis centers. In most for-profit centers, patients must fit the corporation’s system which targets „numbers“ that must be acheived — regardless of patients’ needs. Isn’t it a question of the values, morals and ethics of the nephrologist?
Why has DCI (large non-profit dialysis provider) had better outcomes than Fresenius or DaVita (junk-credit-rating for-profit providers) for more than 15 years?
„Conclusions: Although trials in hemodialysis have typically focused on outcomes such as death, adverse events, and biological markers, patients tend to prioritize outcomes that are more relevant to their daily living and well-being. Researchers need to consider interventions that are likely to improve these outcomes and measure and report patient-relevant outcomes in trials, and clinicians may become more patient-orientated by using these outcomes in their clinical encounters.“
In junk-credit-rating corporations, business executives routinely manipulate financial reports to report optimal results. Failing to ‘hit the numbers’ often results in an even worse credit-rating, increased costs of attaining capital, and a possible stock price collapse.
In order for a junk-credit-rating corporation to succeed in healthcare, its financial successes cannot be seen as the result of providing lower quality care or worse patient outcomes. Unfortunately, the mentality of junk-credit-rating business executives has seeped into patient-related data reporting. In recent years, widespread cheating has been reported in the dialysis industry. This insidious need to report optimal results ultimately leads to a breakdown in the purpose and sanctity of physician-patient relationships.
In junk-credit-rating healthcare corporations, decisions regarding patient care routinely default to the selection that is best for the corporation’s finances. These selections can only be overturned by defiant personal stances or irrefutable scientific evidence. Unfortunately, these instances rarely occur. Junk-credit-rating corporations richly reward executives at the top and — to a less degree — the nephrologists, managers, and employees who are willing to put corporate financial needs first. As a result, far too many patients end up in a junk-bond dialysis hell which no nephrology professional would ever choose for themselves or their family members.
Those who choose not to profit from kidney patients’ illnesses provide better care. This junk-bond-healthcare reality has been staring us in the face for over a decade. DCI, the largest non-profit dialysis provider, has long had the best mortality and hospitalization data in the industry. While DaVita may claim a new rating system shows it provides the best care, the most recent USRDS data shows that DaVita provides the worst outcomes for its patients (see Tables 10.2 and 10.4 in Chapter 10 of the 2015 USRDS report).
DaVita would do much better by its patients to turn its DaVita Patient-Focused Quality Pyramid upside down and instead began its patient interactions by defining the values and activities which are most important to each individual patient.
(In 2015, DaVita led the list of all U.S. companies settling fraud allegations with the government.)
Fresenius Medical Care (FMC) was able to push back to show that GranuFlo® itself did not cause cardiac arrests. What they could not dispute, however, is that GranuFlo product use led to significant buffer (bicarbonate/acetate) dosing errors.
These were largely due to problems with GranuFlo/Acetate display/design errors on the Fresenius Model 2008 dialysis machines. Since close to 90% of dialysis machines in the U.S. were Model 2008 machines, this required FMC to fix over 130,000 dialysis machines over several years.
These problems were finally addressed in these May 2015 FDA recalls for GranuFlo®/Acetate display errors on Model 2008 machines.
It was poor product stewardship on FMC’s part from day one. With GranuFlo, there were a multitude of ways that acetate and bicarb levels could be confused on machines, computer data entry systems, Dr.’s order sheets, treatment forms, etc. When GranuFlo first came out, no effort was made to educate dialysis care providers and clinicians on all the nuances for the correct use of GranuFlo. Today, far more policies and procedures are in place throughout the industry regarding GranuFlo’s use.
When problems were first noticed, most nephrologists did not understand the basics, let alone the complexities, of the acetate/bicarb/GranuFlo issues. This allowed FMC to legally blame nephrologists and clinicians for the dosing problem, but from a long-term sales and business perspective, it was a self-defeating approach. Rather than winning more Pyrrhic victories in court, it was better to settle.
I believe this case shows, along with ESA usage, that the medical professionals who are promoted to the top spots in for-profit dialysis corporations are individuals who tend to put corporate interests before patients’ interests. I also believe this case helps demonstrate that the junk-bond financing of for-profit dialysis care in the U.S. (all medical staff must hit their numbers!) has rotted our system of care to its core.
Why has DCI, a non-profit, had the best mortality and hospitalization data for over a decade?
Patients in thirteen clinics will move from non-profit dialysis care to junk-credit-rating, for-profit-corporation dialysis care.
Which large dialysis provider has the best mortality and hospitalization data? See Tables 10.2 and 10.4 in Chapter 10 of the 2015 USRDS report.
Why would anyone choose worse mortality and hospitalization outcomes for their patients?