For-profit dialysis centers have 20% higher mortality
Low Medicare payments to blame for cost cutting
Patients at for-profit dialysis centers have a 20% higher mortality rate and were 26% less likely to be placed on kidney transplant lists than those treated at nonprofit centers, according to a Johns Hopkins report published in the Nov. 25, 1999 New England Journal of Medicine.
The report also found that "economic pressure, such as the decline in inflation-adjusted Medicare payments for dialysis, may compromise quality of care."
"Given that approximately 140,000 patients were dialyzed in for-profit centers in 1997, more than a third of them diabetics, the increase in the absolute mortality rate among patients in freestanding, for-profit centers suggests that a considerable number of ESRD [end-stage renal disease] deaths may be associated with for-profit treatment," says Neil R. Powe, MD, MPH, MBA. Powe is professor of epidemiology, health policy management, and medicine at Johns Hopkins School of Public Health in Baltimore.
The results were based on data from early 1990s data on 3,569 dialysis patients from the U.S. Renal System, which has opened the study to criticism that the data are old and that the field has changed considerably since then.
"Research studies always have to use old data, there’s no getting around that," says Powe.
But he adds that a new analysis based on later data bear out the initial findings. "The negative effects seen in for-profit facilities may be due to a greater emphasis on income generation. That raises concerns about the current system for payment for dialysis services, which rewards the facility to control costs and maintain patient volume but which does not build in incentives to maximize clinical outcomes."
"This raises ethical questions," notes Powe.
Investigators also cited results of previous studies which showed that for-profit centers are more likely to provide lower doses of dialysis and reuse dialyzers, practices associated with lower costs, but poorer patient survival.
He calls ESRD an "epidemic" and offers some statistics:
• Approximately 34% of ESRD patients are diabetic, and the numbers of new diagnoses are on the increase.
• The number of new cases of ESRD increased by 42.3% in 1996.
• By 1997, 68% of all dialysis patients were being treated in freestanding for-profit units, compared to 53% in 1990.
• Today, there are 3,000 kidney dialysis centers in the country, compared to 2,000 in 1990 and 1,000 in 1980.
Yet with the dramatic increase in numbers of patients suffering with the disease, Medicare increased its payments for dialysis by a minor amount in recent years.
A Health Care Financing Administration (HCFA) spokesman says payments for dialysis increased by 1.2% last year and will increase another 1.2% this year. He says despite the increasing numbers of patients on dialysis, the overall mortality has declined by 24.9% since 1996. The last increase was in 1991.
"We are constantly monitoring quality of care and there is no indication that quality is declining," the HCFA spokesman says.
He also contends that the Johns Hopkins conclusion disagrees with previous analysis of the same data.
HCFA plans to publish mortality rates and outcomes measures on dialysis procedures, possibly by the end of the year, which may help patients and clinicians choose the most appropriate care.
Powe’s team also was critical of the divergence in the numbers of for-profit center patients referred for transplantation — 26% lower than in the nonprofit centers.
For-profit centers were likely to have lower staffing levels, Powe said, which might mean that staff have less time to coordinate patients’ transplant evaluation.
Finally, he suggests, for-profit centers may under-refer patients for transplant in order to maintain patient volumes, and thus income. "Almost every patient should be a candidate for a transplant, every one should have an equal opportunity to be placed on the waiting list."
Garabed Eknoyan, MD, a Baylor University professor of medicine, a practicing nephrologist in Houston, and the National Kidney Foundation’s co-chairman for its Dialysis Outcomes Quality Initiative, counters that not all patients are qualified for transplant. Eknoyan contends that some patients are too weak to survive a transplant or who have other complications precluding a transplant may be sent to centers where chronic patients are treated — and where mortality rates might be expected to be higher.
"The situation is different today, totally different, than at the time these data were collected," says Eknoyan.
The New York City-based National Kidney Foundation (NKF) said the Johns Hopkins study raises "serious" issues. A statement from the NKF also notes that practice has changed, largely since 1994 when the foundation began an initiative to address the fact that the United States has the highest dialysis mortality rate of any industrialized nation for both profit and nonprofit centers. Guidelines were published by NKF in 1997 and "adopted to a great extent by dialysis centers and the government."
Eknoyan says it doesn’t make sense for dialysis centers to allow patients to die in light of treatment costs. "From a business point of view, you don’t want patients to die because you would lose money," he says.
However, Eknoyan says, "Despite my concerns about the study, it raises awareness of the serious issues of dialysis mortality."
The patient advocate group, Tampa, FL-based American Association of Kidney Patients, also noted the age of the data used by Powe and his colleagues. The group issued a written statement saying the data were gathered before current treatment guidelines were put into place and announced its intention to investigate the studies in more detail before deciding on a course of action.
[For more information, contact Neil Powe at (410) 955-4128, the National Kidney Foundation at (800) 622-9010, and the American Association of Kidney Patients at (800) 749-2257.]
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