KIDNEY DIALYSIS: Patients Fare Better at Not-For-Profits

      Kidney failure patients treated at for-profit dialysis facilities are 20% more likely to die and 26% less likely to receive a transplant referral than those visiting not-for-profit centers, according to a new study published Thursday in the New England Journal of Medicine (NEJM). "Our results raise serious concerns that provider decision-making may differ within for-profit organizations, and that the care of patients with end- stage renal disease may be compromised in for-profit facilities," study author Dr. Neil Powe, professor of Epidemiology and Health Policy and Management at Johns Hopkins Medical Institutes, said (Johns Hopkins release, 11/24). The Johns Hopkins and Harvard Medical School study speculated that stagnant Medicare reimbursements, which have remained the same since 1973, may have pushed "centers needing to show a profit to skimp on patient care" by "cutting corners in ways that harmed patients and failing to recommend transplants in order to hang on to customers and keep dialysis payments coming in," the New York Times reports (Grady, 11/25). "If the person gets a transplant, the facility loses that stream of revenue. That's pretty speculative, and that's probably the lesser of the two causes," lead author Dr. Pushkal Garg said. He also pointed to previous studies showing that for-profit facilities tended to have less staff than not-for profit dialysis centers as a possible contributing factor (Johnson, AP/Philadelphia Inquirer, 11/25). Powe added that the discrepancies in quality of care disappeared when for- profit providers were located near not-for-profits, indicating that the "not-for-profits may raise the community standard for quality of care." The new revelations could signal "broader problems in ... a system [that] tends to force hospitals and other caregivers to focus on expenses, rather than quality," he said, noting, "It's an issue our society hasn't grappled well with. We would love to have a corporate involvement in medicine because of the efficiency it may bring in terms of cost, but we also want the best quality of care, and our study suggests that corporations aren't delivering that" (Wall Street Journal, Harris, 11/26). But Margaret Davis of the National Kidney Foundation argued that because the study used old data from 1990 to 1993, it failed to measure industry-wide improvements since 1994. Researchers followed 3,569 kidney failure patients beginning their dialysis in 1990 and 1993 through 1996. "There have been changes in the field of dialysis even in the last four or five years. Everyone has improved overall," she said. Former National Kidney Foundation President Dr. Garabed Eknoyan admitted that "there is greater mortality in the United States than in other countries, and this is a significant problem" but maintained, "It is oversimplistic to say that it's profit as opposed to nonprofit. The issue is harder and more complex than that" (Bernstein, Los Angeles Times, 11/25).

More Bad News
      A second study exploring the gap between the number of black and white kidney patients referred for transplant evaluation "challenges the notion ... that blacks are less likely to choose aggressive care than are whites," the Wall Street Journal reports. Published in Thursday's NEJM, the report reveals that African Americans are "as likely as whites to want a transplant" but often are not informed of the option prior to beginning dialysis. The study found that 76.3% of black women and 80.7% of black men wanted a kidney transplant, compared to 79.3% of white women and 85.5% of white men. However, only half of black women and 53.9% of black men actually were referred for transplant evaluation or put on a waiting list, while 70.5% of white women and 76.2% of men were directed toward the transplant option. Lead author Dr. John Ayanian, assistant professor of medicine and health policy at Harvard Medical School, attributed the discrepancy to poor communication. "The quality of communication between physicians and black patients may not be as good or thorough as it is between physicians and white patients," he said, adding that blacks did not trust doctors as much as whites and were less satisfied with visits (Winslow, 11/26). In response to the report, HCFA last week unveiled a new plan to close the care gap and "ensure that all patients with renal failure, regardless of race or ethnicity are being evaluated for kidney transplantation." The three-pronged strategy aims to remind dialysis centers they must consider all patients for transplantation and to help the End State Renal Disease Network Organization (ESRD), which monitors the quality of care at centers nationwide, collaborate better with patients and facilities to increase transplant assessment rates. Also, HCFA will work with the State Survey Agencies to confirm compliance with Medicare regulations. "All three approaches will enforce and reinforce Medicare's commitment to its ESRD beneficiaries by assuring that they will receive the quality of care that they depend on, including the opportunity to be fully informed about and assessed for transplantation," HCFA Administrator Nancy-Ann DeParle said (HCFA release, 11/24).