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Proposition 8 and how it may impact patient care
Editor’s Note: On Nov. 6, California residents will have the opportunity to determine if dialysis provider profits should be restricted. Nephrology News & Issues asked supporters and opponents of the ballot initiative to present their case.
PRO
Thousands of patients visit dialysis clinics across California nearly every day to receive treatment for kidney failure. The process is long, intrusive and, if not administered in a clean and safe environment, can be deadly. As a dialysis technician who has worked in the industry for 2 decades, I can tell you first hand that the industry too often fails to provide quality care to patients on dialysis.
Clinics are routinely short staffed, leading to dangerous conditions for patients and staff. Patients are aware of this understaffing and it only makes them more anxious, knowing how dangerous their situation is to start.
My worst experience as a dialysis worker occurred in 2016, when a nurse and I were caring for six patients during the last shift at the clinic. After one patient finished her treatment, she exited the clinic and collapsed in the parking lot. I only learned this when her driver desperately banged on the locked clinic door asking for help. I rushed outside to check on the patient and was soon joined by the nurse. While we responded to the fallen patient – who was eventually taken away by ambulance – we left five patients unattended for 15 minutes. Upon returning to the clinic, I saw one patient crying because she was scared. I was, too.
On my drive home that evening, all I could think about were the patients and their families: the one who collapsed and how her family had no clue what was happening; and the other five who were left unattended in the clinic and how their family members did not know if they were safe. When I got home, I hugged my family.
Problems abound throughout California. Dialysis workers and patients have reported clinics across the state with cockroaches, gnats, mice and dried blood – unsanitary conditions that increase patients’ risk of infection. That is why it’s time for change in the dialysis industry.
Proposition 8 would improve dialysis patient care. It does so by limiting dialysis corporate profits to 15% above the cost of care, with any profits above that amount being refunded to those paying for dialysis – whether that is an individual patient or an insurance company.
Critics of Prop. 8 ask how such a mechanism would lead to improved patient care. It is simple: Instead of being forced to refund excessive profits to insurance companies, the dialysis industry can avoid that scenario by investing more in patient care, including hiring more staff, buying new equipment and improving facilities.
For example, if it currently costs DaVita and Fresenius $2 billion a year to care for their patients on dialysis in California, under Prop. 8 they could make a profit of $300 million. Any profits above that amount would be refunded to the consumer or the insurance company.
However, I think people throughout the industry can agree that more needs to be spent on staffing, equipment and facilities – and the companies could do that without penalty under Prop. 8. One way the dialysis industry can comply with Prop. 8 is to spend more on services that directly benefit patients.
In other words, if DaVita and Fresenius decided it costs $4 billion a year to provide safely staffed clinics with functioning equipment and sanitary facilities in California, they could plow the additional amount (above the original amount of $2 billion a year) into those services and still make a profit of $600 million – without having to refund even $1 to insurance companies.
This incentive is what inspired more than 130 health care advocacy groups, civil rights organizations, labor unions – including the California Professional Firefighters, faith organizations, veterans’ groups and community associations – to support Prop. 8. Patients on dialysis will receive better care. Workers will receive more support from employers. Corporations will still make a profit. It is a situation in which California can lead the country on improving patient care and protecting lives at the same time.
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Mike Borja is a dialysis patient care technician who lives in Sacramento, California. Disclosure: Borja reports no relevant financial disclosures.
CON
I have been treating patients with ESRD for more than 30 years. Never in my career have I seen a threat more severe to the health and welfare of my patients than what is posed by Proposition 8, the flawed dialysis measure on California’s November ballot. Unless defeated, Prop. 8 will jeopardize the dialysis safety net and create serious health risks for patients who need this treatment to survive.
Prop. 8 is opposed by health care leaders and more than 120 other organizations including the Renal Physicians Association, California Medical Association, American Nurses Association, California, emergency room physicians, patient advocates, dialysis providers and many others in California. It sets severely low limits on what health insurance companies are required to pay to community dialysis clinics for dialysis treatments. These low reimbursement levels would not cover the cost of providing high-quality care. For example, the initiative specifically prohibits clinics from billing for necessary work by clinic medical directors, nurse clinical coordinators, nurse managers and other critical staff positions along with insurance, human resources, payroll, legal and other costs.
According to an independent study by the Berkeley Research Group, Prop. 8 will only allow dialysis clinics to recover 69% of the costs necessary to stay open, and 83% of clinics in California would go from operating in the black to operating in the red with an average minus 8% operating margin in California. No dialysis clinic can sustain losses like that indefinitely.
The net effect of Prop. 8’s passage would be the closure of dozens of clinics across the state, particularly in low-income and rural areas. That would create a chain reaction that could ultimately threaten the lives of kidney patients. Clinic closures would mean people would have to travel farther for treatments. In rural areas, this could mean traveling hundreds of miles more per week for the three weekly treatments. If Prop. 8 passes and access to care is limited, kidney patients would be more likely to miss or skip routine dialysis treatments. Just one missed treatment increases mortality risk by 30%. Clearly, this will result in worse health outcomes for patients and higher costs for taxpayers.
In addition, if dialysis access becomes too restricted and patients have no options for dialysis nearby, they will have no alternative but to go to the hospital emergency room for routine dialysis treatment. This will be more expensive to patients who may have to pay a significant copay for emergency room visits, more expensive to Medicare and Medi-Cal, which is the state’s version of Medicaid, taxpayers and the health care system. Ultimately it could cost the health care system hundreds of millions of dollars.
The state’s nonpartisan legislative analyst’s office (LAO) reviewed Prop. 8 and its analysis appears in the California voter pamphlet mailed to 19 million registered voters in California. The LAO raised concerns about the potential for increased Medi-Cal expenses for California taxpayers and reductions in available care for the patients who need it.
That would be disastrous for kidney patients in California. Demand for dialysis in California is increasing at more than 5% a year and patients on dialysis already have difficulty getting appointments with kidney specialists.
Most of the patients I treat in Alameda, Contra Costa and Solano counties are low-income. Of the patients I treat at one clinic in Oakland, about one-third are African American, one-third Latino and another 25% are Southeast Asian. Unfortunately, those who would be hurt most if Prop. 8 passes would be patients like mine – low-income residents who depend on availability of dialysis clinics nearby to receive their dialysis treatments three times a week.
Dialysis is one of the most heavily regulated components of health care. Dialysis clinics must adhere to 376 unique regulations and are surveyed for compliance with each of those. Patient quality care is routinely measured. Patients nationwide are sent surveys annually and are asked about their satisfaction with everything from their physicians, clinic and clinic staff.
On all measures of patient quality and patient satisfaction, California is surpassing the rest of the nation. According to the latest publicly available data from CMS, which regulates dialysis clinics nationwide, California outranks the national average in both patient quality care and patient satisfaction. California also has a 16% lower infection rate than the national average.
As a nephrologist, my concern is for my patients and their well-being. I have devoted my professional life to their care and I am committed to doing what I can to protect them from harm. That is why I am so strongly opposed to Prop. 8 and will work to ensure its defeat.
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Bryan Wong, MD, is a nephrologist with East Bay Nephrology Group in San Pablo, California. Disclosure: Wong reports no relevant financial disclosures.