Re: [IP] Dialysis in N.Y. Lags as Diabetes Ruins Kidneys
Here it is for those who want the article for keeping:
December 28, 2006
Dialysis in N.Y. Lags as Diabetes Ruins Kidneys
By RICHARD PIREZ-PEQA
Tens of thousands of people across the country, their kidneys ruined
by Type 2 diabetes, have been forced into the grim routine of
dialysis care, and in New York, those patients routinely receive some
of the worst treatment, government records show.
At New York dialysis centers, those being treated are more likely to
suffer from anemia and are less likely to have enough impurities and
excess fluid removed from their blood, allowing more damage to their
bodies, according to the records.
Experts say the disparity is caused in part by the fact that New York
is dominated by small dialysis providers, many of them run by people
with little background in medicine who entered the business to meet
the surging demand.
Many of the smaller centers provide good care, experts say, but a lot
also lack the money and staff training to compete on a quality-of-
care basis with the national dialysis chains that dominate the market
across the rest of the country.
Newly released patient data show that people who receive their
dialysis from a national chain generally fare better than those
treated by an independent provider.
But the chains are largely blocked from operating in New York by a
state law that effectively bars publicly traded companies from owning
health care facilities in the state.
With the need for dialysis on the rise, the department is
questioning whether it makes sense not to allow these large
corporations to participate, said Jeffrey W. Hammond, a Department
of Health spokesman.
In 1980, fewer than 50,000 people in the United States needed
dialysis to do the work of their kidneys; today, there are more than
350,000, including roughly 24,000 in New York. In 1980, diabetes was
the primary cause of kidney failure for fewer than 6,000 dialysis
patients; today, the figure is about 150,000.
Survival for them is an ordeal, at best.
At a typical dialysis center, patients come in three times a week,
typically for four hours at a time. They sit in rows of recliners,
dozing, watching television anything to take their minds off the
machines, needles and tubes that siphon blood from their bodies,
clean it of impurities like urea, and pump it back in. It is
surprisingly quiet; patients are so beset by side effects like
fatigue, cramps or thirst, that mere conversation seems like an effort.
For all but a few, holding a job is out of the question. Most will
never be healthy enough to qualify for a transplant that would free
them of this burden, and there are far too few donated kidneys, anyway.
New drugs and dialysis techniques have improved their chances of
survival since the 1980s, despite the fact that patients today are
older, heavier and sicker. Even so, the average dialysis patient
spends 15 days a year hospitalized, and the death rate is about one
in five each year.
I want to say its a rough life, but it hardly is a life, said
Denise Bembury, a dialysis patient who lives in Brooklyn. I wouldnt
put this on anybody.
Across the country, five companies own or operate almost two-thirds
of the 4,800 dialysis units. Two of them, Fresenius Medical Care and
DaVita, have more than half the market. But in New York, the big five
run about 20 percent of the roughly 250 centers, by far their lowest
share in any state.
The State Department of Health has helped the national chains work
around the law that bars publicly traded companies from owning health
facilities. This has allowed them to open some centers here, but the
companies say the approval process remains long and difficult,
dampening their interest.
The ownership restriction, in place for at least 50 years, state
officials said, was enacted when there was no such thing as a
dialysis center, and was intended to ensure that hospitals are
responsive to local concerns, not to far-flung shareholders. Though
the Health Department talks of changing the law, no one has made it a
priority, and not even the large chains have pushed the issue in Albany.
Recent reports on the quality of dialysis care by the federal Centers
for Medicare and Medicaid illustrate New Yorks cause for concern.
The centers examined a sampling of Medicare patients dialysis
records in each of 18 regions, one of them New York State.
Medicare pays for almost 90 percent of dialysis in this country, and
in the reports, for 2003 and 2004, New York ranked worst in all three
of the most commonly used quality measures. Those measures are how
likely patients are to have enough excess fluid like water removed
from their blood during dialysis, how likely they are to have enough
impurities like urea removed, and how likely they are to be anemic or
severely anemic because of the treatment.
Those scores have improved in New York over the last decade, but not
as quickly as they have nationwide, and New Yorks numbers were
actually worse in 2004 than in 2003.
The federal agency does limited comparisons of individual dialysis
centers, which show that nationally, 4 percent of them have unusually
poor patient survival rates, defined as at least 20 percent below
average. In New York, 12 percent do. Federal officials caution
against putting much stock in any one centers numbers, but they say
the regional picture clearly shows a problem.
The federal data do not draw any conclusions about the cause of the
disparity. But experts said they believed the quality of care was
affected by the high number of smaller, less experienced providers in
the New York market. In fact, in New York City, one-fifth of the
centers operating earlier this year had existed for less than five
A recent report by the United States Renal Data System Coordinating
Center, a quasi-governmental agency that compiles the records of most
dialysis patients, shows that patients at the major chains were less
likely to die than those treated by smaller companies.
According to the center, the numbers were adjusted to account for
differences that might affect patients risk, like age and sex,
whether they had an underlying disease like diabetes and how long
they had been on dialysis. The independents were defined as not being
part of a major chain or a hospital.
Four of the five largest chains had adjusted death rates 7 percent to
10 percent lower than the independents had as a group in 2004, and
one chain had higher rates, according to the centers most recent
annual report. Since then, two major chains, including the one with
the highest death rate, have left the business, and two new ones have
Patients at the small companies were much more prone to infections
that led to hospitalization or death. The small companies also lagged
in nondialysis care that dialysis centers usually take over, like
ensuring that patients get vaccinations for influenza, pneumonia and
hepatitis B. Their diabetic patients were less likely to have tests
that monitor blood sugar control.
Some independent operators say that large companies can cherry pick
healthier clients. But the governments figures show that the
national chains patients are actually sicker when they begin
dialysis more anemic, more overweight, and with more advanced
Researchers and state and federal officials say they have known, or
at least suspected, for years that patients fare better at the major
chains, but they cannot be sure why.
One factor believed to play a role is that the average Medicare
reimbursement rate for a dialysis session, $140 to $150, has changed
little since the 1970s, making it difficult for the smaller operators
who cannot realize economies of scale. Tight operating margins have
left fewer small providers nationwide, although their numbers have
grown in New York, where the chains have not been able to operate
Dr. Allan J. Collins, director of the United States Renal Data System
Coordinating Center, said: We do know that the large organizations
have an enormous advantage in resources because they can demand
discounts from suppliers on drugs and equipment, and that can
translate to better staffing, better training. The chains also tend
to be more systematic and standardized in their procedures.
Michael Paget, executive director of the National Renal
Administrators Association, which represents large and small dialysis
companies, said he was not familiar with the Coordinating Centers
research that indicates one group performs better than the other. The
center first included those comparisons in a report last year, and
first included the mortality and hospitalization breakdowns this year.
I dont think you can generalize about the independents, and there
are many that do an excellent job, outperforming even the best of
the major chains, he said. But he acknowledged that bigger companies
probably had an edge in training.
The federal government and most states, including New York, do not
set training or educational standards for dialysis technicians, the
workhorses of a dialysis center. (Federal rules require only that the
centers have full-time or part-time doctors, social workers and
nurses on staff.)
National chains customarily provide technicians and other staff
members with months of initial training and occasional re-training,
instruction that can boost the quality of care and that independent
companies, with their tighter operating margins, have a hard time
affording, experts say.
Ms. Bembury, 44, uses an independent center, Nephrocare, a three-year-
old unit on Atlantic Avenue, in the Weeksville section of Brooklyn.
She goes there, she said, because her doctors referred her there.
Like many patients, she has no idea how it compares with other
centers, or how to find out.
Until earlier this year, she was a social worker and an avid cook.
Now, she is on disability, and her companion of more than 30 years
prepares meals. They have six children, and she wonders how the four
youngest, all teenagers, will manage.
Im thirsty all the time, and tired, she said.
Nephrocare was one of a few dozen centers in New York with an
abnormally high death rate in 2004, though not in 2005, and in both
years, it had an unusually high number of patients with uncontrolled
anemia, Medicare records show. An administrator at Nephrocare said
that none of the owners or staff would be interviewed, and several
other large, independent centers around the city gave the same response.
There are no rules as to who can own or manage a dialysis center.
Doctors control some. Others are run by people with no background in
health care. State officials say they conduct a character and
competence review, and look at owners finances.
Under Medicare rules, states must inspect most centers every three
years, though troubled centers are visited more often. Even when
there are persistent problems, regulators would rather coax a center
into improving than shut it, even temporarily, because the dialysis
supply barely keeps up with demand.
State officials said they could recall only one center being forced
to close this decade, and Medicare gave that order, not the state.
The experience was painful, they said, as patients had trouble
finding other centers nearby with spaces, or stations, available.
We had 403 people who had to find other stations in New York City,
said Mr. Hammond, the department spokesman, and that is not
something we encourage or want to happen.
On Dec 28, 2006, at 8:11 AM, Sue Kinzelman wrote:
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