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PORTSIDE  December 2010, Week 4

PORTSIDE December 2010, Week 4


In Dialysis, Life-Saving Care at Great Risk and Cost


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In Dialysis, Life-Saving Care at Great Risk and Cost
by Robin Fields
November. 9, 2010

In 1972, after a month of deliberation, Congress
launched the nation's most ambitious experiment in
universal health care: a change to the Social Security
Act that granted comprehensive coverage under Medicare
to virtually anyone diagnosed with kidney failure,
regardless of age or income.

It was a supremely hopeful moment. Although the
technology to keep kidney patients alive through
dialysis had arrived, it was still unattainable for all
but a lucky few. At one hospital, a death panel -- or
"God committee" in the parlance of the time -- was
deciding who got it and who didn't. The new program
would help about 11,000 Americans, just for starters.
For a modest initial price tag of $135 million, it would
cover not only their dialysis and transplants, but all
of their medical needs. Some consider it the closest
that the United States has come to socialized medicine.

Now, almost four decades later, a program once
envisioned as a model for a national health care system
has evolved into a hulking monster. Taxpayers spend more
than $20 billion a year to care for those on dialysis --
about $77,000 per patient, more, by some accounts, than
any other nation. Yet the United States continues to
have one of the industrialized world's highest mortality
rates for dialysis care. Even taking into account
differences in patient characteristics, studies suggest
that if our system performed as well as Italy's, or
France's, or Japan's, thousands fewer patients would die
each year.

In a country that regularly boasts about its superior
medical system, such results might be cause for outrage.
But although dialysis is a lifeline for almost 400,000
Americans, few outside this insular world have probed
why a program with such compassionate aims produces such
troubling outcomes. Even during a fervid national debate
over health care, the state of dialysis garnered little
public attention. Get ProPublica's investigations and
major stories delivered to your inbox. [1]

Over the course of more than a year, ProPublica reviewed
thousands of inspection reports and interviewed more
than 100 patients, advocates, doctors, policy makers,
researchers and industry experts to get a grasp on
American dialysis. The findings were bleak: At clinics
from coast to coast, patients commonly receive treatment
in settings that are unsanitary and prone to perilous
lapses in care. Regulators have few tools and little
will to enforce quality standards. Industry
consolidation has left patients with fewer choices of
provider. The government has withheld critical data
about clinics' performance from patients, the very
people who need it most. Meanwhile, the two corporate
chains that dominate the dialysis-care system are
consistently profitable, together making about $2
billion in operating profits a year.

One reason the system's problems have evolved out of the
health care spotlight is that kidney failure
disproportionately afflicts minorities and the
dispossessed. But given a patient pool growing by 3
percent a year and the outsize 6 percent bite that the
kidney program takes from the Medicare budget, we ignore
dialysis at our own risk. "We're offering our patients a
therapy we wouldn't accept for ourselves," said Dr. Tom
F. Parker III, a Dallas nephrologist and national
advocate for better care. More and more leaders in the
field, he said, "are starting to say this isn't

As the United States moves to expand access to health
care, dialysis offers potent lessons. Its story
expresses the fears of both ends of the ideological
spectrum about what can happen when the doors to care
are thrown wide open: Neither government controls nor
market forces have kept costs from ballooning or ensured
the highest-quality care. Almost every key assumption
about how the program would unfold has proved wrong.

The Sharp End of the Needle Henry Baer, right, with his
mother, Violet Cunningham. Baer, 39, died from an
antibiotic-resistant staph infection after his bloodline
had become disconnected during a dialysis treatment.
(Photo courtesy of Karen Gable)

Henry Baer, right, with his mother, Violet Cunningham.
Baer, 39, died from an antibiotic-resistant staph
infection after his bloodline had become disconnected
during a dialysis treatment. (Photo courtesy of Karen

Henry Baer went in for his third dialysis treatment on
New Year's Eve day in 2005. It turned out to be his
last. He was only 39, but years of diabetes and high
blood pressure had caused Baer's kidneys to shut down.
Built-up waste and fluid were causing his limbs to swell
and making him short of breath. He was sent for what's
called in-center hemodialysis [2], the most common type
of dialysis, at a beige-toned clinic near his home in
Prescott Valley, Ariz.

His first two sessions were pretty normal. A patient-
care technician hooked Baer to a machine the size of a
filing cabinet, connecting it with plastic tubing to the
catheter in his chest. He sat in a lounge chair, still
as stone, for about four hours as the machine, whirring
gently, moved his blood through a specialized filter,
then returned it, cleansed of toxins. It was
uncomfortable and boring. "Sis, this isn't for me," he
told his older sister, Karen Gable, vowing to make
himself a viable candidate for a kidney transplant.

Just over two hours into his next session, Baer's
incoming bloodline "became disconnected," a federal
inspection report [3] says. The attending technician
panicked, "yelling and screaming hysterically." Blood
sprayed onto Baer's shirt, pants, arms and hands. Then,
"contrary to emergency standing orders," the report
continued, she reconnected the line to Baer's catheter,
infusing him with "potentially contaminated blood." By
the time Mike Wright, Baer's boss at a local car
dealership, picked Baer up after the treatment, he was
complaining of nausea.

Over the next two days, Baer spiked a fever. His wife
found him in bed, having a convulsion. He was taken to
the hospital, where tests later showed that his catheter
had become infected with antibiotic-resistant staph. The
infection moved swiftly to his heart and brain. He died
a few days later, on Jan. 7, 2006, leaving behind a 2-
month-old daughter. (Fresenius Medical Care North
America, the clinic's operator, declined to comment on
the incident, citing patient privacy rules. In 2008,
without admitting wrongdoing, it agreed to settle a
wrongful-death lawsuit brought by Baer's survivors.)

What happened to Baer was a worst-case scenario. Yet in
some ways it is symptomatic of how dialysis is
delivered. Medical supervision is minimal. Clinics must
have board-certified physicians as medical directors,
but usually have no doctor on site, and some struggle to
meet the federal requirement of at least one full-time
registered nurse. Technicians, who can start with just a
high-school diploma and an in-house course (though they
are later required to pass a state or national
certification test), have been the field's workhorses
for a generation. Medicare sets no staffing ratios for
dialysis centers, and most states don't either.

Although some clinics are orderly and expert --
attentive not only to patients' health, but also to
their dignity -- others are run like factories, turning
over three shifts of patients a day, sometimes four.
Safety experts say technicians shouldn't monitor more
than four patients at once, but some operators save
money by stretching them further. The pace can be so
intense, inspections show, that clinics have allowed
patients to soil themselves rather than interrupt
dialysis for a bathroom break. One technician said he
quit his job at a large Colorado clinic because he often
had to juggle six patients or more. "The last two years,
I was just getting old," he said.

Conditions within clinics are sometimes shockingly poor.
ProPublica examined inspection records for more than
1,500 clinics in California, New York, North Carolina,
Ohio, Pennsylvania and Texas from 2002 to 2009.
Surveyors came across filthy or unsafe conditions in
almost half the units they checked. At some, they found
blood encrusted in the folds of patients' treatment
chairs or spattered on walls, floors or ceiling tiles.
Ants were so common at a unit in Durham, N.C., that when
a patient complained, a staffer just handed him a can of
bug spray.

Hundreds of clinics were cited for infection-control
breaches that exposed patients to hepatitis, staph,
tuberculosis and HIV. A Manhattan center closed in 2008
after cross-contamination infected three patients with
hepatitis C within six months. Prescription errors were
common: 60 clinics had at least five citations for them.
In dozens of instances, patients died or were
hospitalized after suffering hemorrhages like Baer's,
when dialysis needles or tubing dislodged and staffers
failed to adhere to safety guidelines. 

Providers [4] say [5] they work hard to meet or exceed
government standards, correcting deficiencies quickly
when they surface and sometimes employing their own
internal auditing programs. "You will find cases where
things go wrong, but it's a small percent when you
consider all of the hundreds of thousands of treatments
every day," said Diane Wish, the CEO of a small Ohio
dialysis chain and president of the National Renal
Administrators Association, the group that represents
dialysis facility managers. But patient advocates say
conditions in some clinics have been problematic for so
long that everyone in the system has come to accept it.
"It's become ingrained that dialysis is expensive and
dangerous and has terrible outcomes," said Bill Peckham,
a patient known widely for his blog, Dialysis From the
Sharp End of the Needle [6]. "Once you're there, God
help you. What do you expect? You're on dialysis."

Rise of an Entitlement

Dialysis entered the American consciousness in the early
1960s as the country's signature example of medical
rationing. In those days, kidney disease killed about
100,000 people a year. Chronic dialysis was possible,
thanks to two inventions: the artificial-kidney machine
developed by the Dutch doctor Willem Kolff during World
War II and a vascular-access device designed by Belding
Scribner, a pioneering Seattle physician who opened the
first outpatient dialysis center in the United States.
But treatments were expensive, and most private insurers
would not pay for them. At Scribner's medical center,
the Life or Death Committee parceled out the few slots,
weighing not only the health of patients and their
income, but also their perceived social worth.

News reports about the committee's work sparked one of
the earliest national debates over the right to care and
put pressure on the government to step in. A turning
point came when Shep Glazer, vice president of the
largest patient group, made an emotional appeal to the
House Ways and Means Committee as he underwent dialysis
on the hearing-room floor. "If your kidneys failed
tomorrow, wouldn't you want the opportunity to live?"
asked the 43-year-old father of two. "Wouldn't you want
to see your children grow up?"

The measure [7] establishing taxpayer funding for
treatment of end-stage renal disease, signed into law by
President Richard M. Nixon, was expansive, and its
lopsided, bipartisan approval reflected the times. Many
lawmakers -- even conservatives -- thought the United
States would adopt a European-style national health care
system. Also, the program that took effect in July 1973
was expected to have about 35,000 patients and cost
about $1 billion in its 10th year.

Those estimates came to seem almost laughable. The
number of dialysis patients surpassed 35,000 by 1977 and
has gone up from there. The growth reflected not only
lower-than-expected transplant rates and the spread of
diabetes, but also positive trends, like better cardiac
care. With Americans living long enough for their
kidneys to fail and no disqualifying conditions for the
program, even the oldest and sickest patients
increasingly were prescribed dialysis. Upwards of
100,000 now start treatment each year. "It's been a
perfect example of that line, 'Build it and they will
come,'" said Dr. Jay Wish, director of dialysis services
for University Hospitals Case Medical Center in

Because the kidney program absorbed that unforeseen wave
-- and thus prolonged so many lives -- some call it one
of the great success stories of modern medicine. Still,
the annual bill for the program quickly outpaced early
projections, surging past $1 billion within six years.
Per-patient expenditures were expected to drop as
technology advanced. Instead they have risen steadily,
as drug and hospitalization costs grew for the program's
increasingly frail clientele.

Medicare has struggled to enforce quality standards for
dialysis while meeting its prime directive of providing
universal access. As the medical community's
understanding of kidney disease grew, the government set
biochemical targets for improving care. Clinics got
better at hitting them, but overall rates of death and
hospitalization have seen little change. And Medicare's
record of making sure that clinics meet health and
safety standards has been spotty. Clinics are supposed
to be inspected once every three years on average, but
as of October, almost one in 10 hadn't had a top-to-
bottom check in at least five years, as shown by data
from the Centers for Medicare and Medicaid Services [8]
(known as CMS). About 250 facilities hadn't had a full
recertification inspection in seven years or more.
Nursing homes, by contrast, must be inspected once every
15 months, and in 2006, CMS reported that 99.9 percent
had been.

Even when inspectors find that clinics are not meeting
government standards, the consequences are seldom
meaningful. CMS can demand that facilities submit
correction plans, but it cannot fine violators as it can
nursing homes. The agency almost never imposes its
toughest sanction -- termination from Medicare --
because clinic closures could hinder access to care.
From 2000 to 2008, the agency barred just 16 dialysis
facilities; federal regulations set no limits on how
many violations are too many. "It's a judgment call,"
said Jan Tarantino, deputy director of CMS's survey-and-
certification group.

When the Memphis University Dialysis Center was
terminated from Medicare in June 2007, the step had been
at least four years in the making. During that time, the
clinic was flagged for dangerous conditions, inadequate
care, higher-than-expected mortality rates and subpar
clinical results. CMS threatened to yank the unit's
certification in March 2006 and again the following
year. Both times, however, even though inspectors
continued to find problems, the agency allowed the
clinic to stay open. James 'Tug' McMurry, 66, died after
suffering a devastating brain hemorrhage. Staffers at
the Memphis University Dialysis Center, where McMurry
received his treatments, had given him extra doses of a
clot-dissolving medicine. 

James 'Tug' McMurry, 66, died after suffering a
devastating brain hemorrhage. Staffers at the Memphis
University Dialysis Center, where McMurry received his
treatments, had given him extra doses of a clot-
dissolving medicine. 

In April 2007, nine days after CMS sent the center a
letter confirming that it was back in compliance, 66-
year-old James "Tug" McMurry came in for treatment. When
he had slow blood flow after being given his regular
dose of blood thinner, staffers administered doses of a
clot-dissolving medicine, according to a CMS survey [9].
Later, a nurse told inspectors that a doctor had given a
verbal order to administer the drug, but the doctor
denied it, writing [10] "This order was not given by me"
on a form.

McMurry called one of his sisters, Betty Tindall, on his
way home that day. "He said, 'They don't know what
they're doing up there,'" Tindall recalled. A couple of
hours later, McMurry's neighbor heard him bang on the
shared wall between their apartments. "Help! Help!" he
yelled. Paramedics found him slumped in a chair,
vomiting. Tests at the hospital showed McMurry had
suffered a devastating brain hemorrhage. By the time
family members made it to his bedside, he was in an
irreversible coma.

In an inspection three weeks later, regulators cited
Memphis University Dialysis for failing to provide "safe
dialysis services" and violating rules on the proper
administration of drugs. They found multiple errors
involving blood thinners, including one that resulted in
the hospitalization of another patient. This time, CMS
revoked the dialysis unit's Medicare certification,
prompting it to close. "It took people dying before they
did anything," said Bobby Martin, an attorney for
McMurry's brother and sister-in-law, who reached a
confidential settlement with DaVita Inc., the clinic's
owner, in August 2009. (A DaVita official declined to
comment on the case, citing patient privacy.)

CMS officials disputed the idea that they had acted too
slowly. "Please understand that this is not an easy
decision," said Jessica Jenkins, a spokeswoman for the
regional office that handled the matter. "We're not in
the business of putting facilities out of business."

Coke or Pepsi

Problems like those that regulators found in McMurry's
clinic are partly rooted in economics. The government's
payment policies for dialysis have created financial
incentives that, in some ways, have worked against
better patient care, while enabling for-profit
corporations to dominate the business.

When the end-stage-renal-disease program began,
hospitals provided most of the care on a nonprofit
basis. But spurred by the guarantee of Medicare money,
the marketplace met the growing demand for services
through the expansion of for-profit companies. Today,
more than 80 percent of the nation's 5,000 clinics are
for-profit. Almost two-thirds of all clinics are
operated by two chains: Colorado-based DaVita and
Fresenius, a subsidiary of a German corporation that is
the leading maker of dialysis machines and supplies.

From the start, the government's payment rules rewarded
efficiency. Medicare set a rate for dialysis treatments,
originally $138 per session, and covered a maximum of
three treatments a week for most patients. Providers
could keep whatever they didn't spend on care. There
were no penalties for poor results and no bonuses for
good ones. Unlike other Medicare rates, the payment
wasn't adjusted upward for inflation.

Lawmakers cut the base rate to about $123 per treatment
in 1983, after the program's cost came in higher than
expected and audits showed providers averaging profits
of more than 20 percent. Dialysis companies responded
like any other business facing a drop in prices, said
Philip J. Held, a nationally recognized researcher on
kidney disease and an economist by training. They
chopped expenses by shortening treatments, thinning
staff and assigning tasks once done by nurses to
unlicensed technicians. Some reused dialyzers, the
filters that clean a patient's blood. "It changed the
nature of the service," Held said of the rate cut. "You
get what you pay for. The price was lower, but the
product was dramatically different."

The government created another perverse incentive by
allowing clinics to bill Medicare separately for certain
medications, reimbursing them at a markup over what they
paid drug makers. Dialysis companies embraced the
opportunity: Doses of Epogen, prescribed to treat
anemia, and similar medications tripled between 1989 and
2005, becoming Medicare's single largest pharmaceutical
expense. "Their core business became giving patients
injectable drugs," said Richard A. Hirth, a professor of
health management and policy at the University of
Michigan School of Public Health. "Dialysis was just the
loss leader that got [patients] in the door." 

Though lucrative for clinics, the drug boom -- much like
the service cuts -- may have undermined patient care. A
2006 study showed that patients treated with higher
doses of Procrit, a medication similar to Epogen, were
at greater risk for heart problems and death than those
who got lower doses.

As a whole, the government's payment rules have given
big providers, with their economies of scale and
purchasing power, a financial edge over smaller ones,
spurring consolidation. DaVita and Fresenius each now
have at least 1,500 clinics and more than 120,000
patients in the United States. No other operator has
more than 300 clinics.

The chains say their deep pockets support quality
initiatives that smaller providers can't match. "One of
the advantages of being large ... is that you can invest
in trying new things and being innovative," said Dr.
Allen Nissenson, DaVita's chief medical officer. The Big
Two are evolving into one-stop-shopping outlets for
dialysis-related services: They run labs, pharmacies and
clinics that specialize in vascular access. They have
moved into the home-dialysis market and sell drugs used
by dialysis patients. In 2009, the dialysis giants
booked combined North American operating profits of $2.2
billion, their most ever.

In public financial filings, the companies say Medicare
payments do not fully cover the cost of treatments and
attribute much of their profit to the small minority of
patients covered by private insurers, who pay
substantially higher rates. DaVita says its margins are
slimmer than those of the health care sector overall. In
a March 2010 report [11] (PDF), the independent Medicare
Payment Advisory Commission judged pay for dialysis and
related services to be adequate, calculating that in
2008, one-quarter of U.S. clinics had Medicare margins
of at least 13 percent while another quarter lost money.
The two largest providers averaged Medicare margins of 4
percent, the commission found, more than twice that of
all others.

Some smaller operators are struggling. For the past
several years, the Independent Dialysis Foundation, a
nonprofit with nine clinics in Maryland, has run in the
red. The founder, Dr. John Sadler, a pioneer in
dialysis, said he has refused offers to sell because he
believes independent operators offer a crucial
alternative to chains. But Sadler admitted to a growing
sense of futility. "Perhaps people like me are
dinosaurs," he said. "I've always thought our focus on
patients, not profits, was important."

Many within the dialysis world share Sadler's uneasiness
with the dominance of for-profit providers overall and
chains in particular. Over the past decade, stacks of
competing studies have attempted to parse whether the
quality of care at for-profit centers is equal to that
at nonprofit centers, with no clear-cut answer. The
expanding grip of DaVita and Fresenius may make such
debates moot. Though the U.S. has more dialysis clinics
than ever, patients don't necessarily have more choice.
"It's Coke and Pepsi," said Joseph Atkins, who has been
in the industry for 37 years as a technician, nurse,
clinic owner, and consultant. "And in some places, it
can be Coke or Pepsi."

'I Don't Have Nowhere Else to Go'

Even as government policies have encouraged the spread
of corporate dialysis, they have largely denied
consumers the chance to use market power to push for
better care. Because Medicare is the dominant payer, it
has information about dialysis centers that doesn't
exist for other medical providers. Yet the Centers for
Medicare and Medicaid Services has not made public key
measures such as clinics' rates of mortality,
hospitalization for infection and transplantation.
Regulators know how dialysis units perform by these
yardsticks. So far, patients don't.

Mark Schlesinger, a professor at the Yale School of
Public Health, says the program has squandered an
opportunity to be a model of patient empowerment. "In
some ways, [dialysis] is where Medicare has the biggest
footprint, but it's always been kind of a backwater," he
said. "There's a perception that these patients won't
take advantage of the opportunities."

ProPublica first asked CMS for the clinic-specific
outcome data it collects -- at taxpayer expense -- two
years ago under the Freedom of Information Act. The
agency declined to say whether it would release the
material until last week, as this story neared
publication. It subsequently has provided reports for
all clinics for 2002 to 2010. ProPublica is reviewing
the data and plans to make it available for patients,
researchers and the general public.

The reasons CMS has given for withholding the
information until now is that some measures are disputed
or lack refinement. Regulators and providers can put the
data in perspective, officials had said, but patients
might misinterpret the information or see it as more
than they really want to know.

CMS's Dialysis Facility Compare website [12] posts a
handful of measures, including one for mortality, but
does not give hard numbers. Instead, it categorizes
patient-survival rates as "better than expected," "worse
than expected" or "as expected." "Mortality is hard for
individuals to face," said Thomas Dudley, who oversees
Dialysis Facility Compare. "You don't want to scare
people away." Peckham, the patient-advocacy blogger,
scoffed at this. "It infantilizes people to say, 'We
don't want to burden you with information and facts,'"
he said.

Would more information make a difference? ProPublica was
able to obtain outcomes data directly from the state of
Texas for more than 400 clinics there. The material,
covering 2007-09, reveals striking differences between
clinics in close proximity.

Innovative Renal Care and Midtown Kidney Center, clinics
about two miles apart in Houston, had similar stats on
Dialysis Facility Compare in 2007, including "as
expected" survival rates. But the full data show that
Innovative Renal's average annual death rate -- after
factoring in patient demographics and complicating
conditions -- was 34 percent higher than expected [13].
Midtown's average rate was 15 percent lower than
expected [14]. Dialysis Facility Compare has since
changed Innovative's survival rating to "worse than
expected," but how much worse? The unpublished 2009 data
reveal that the clinic performed more poorly, versus
expectations, than 92 percent of all facilities
nationwide [15]. Innovative Renal's administrator, Scott
Sullivan, said the clinic had a difficult patient pool,
but its most recent results have shown improvement.
"We've put things in place to make sure those numbers
are corrected," he said.

The information void feeds patients' general sense of
powerlessness. Even activists such as Peckham or Lori
Hartwell, who heads up the Renal Support Network [16], a
patient advocacy group, say they often feel shut out of
the biggest decisions affecting the dialysis system. As
a group, those on dialysis have been less vocal and
effective than other patient communities in pressing a
cohesive agenda. Kidney failure is almost four times as
common among African-Americans as among whites, and
about one and a half times as common among Hispanics as
among non-Hispanics. About half of the kidney program's
beneficiaries are poor enough to qualify for Medicaid.
Dialysis itself can leave many patients saddled with
cramps, congestion and a sapping exhaustion. "You're a
pile of mush that's barely getting through," said Cindy
Miller, a former patient in Las Vegas who got a kidney
transplant. "What do you want to do, file a class
action? How many of these people are going to be alive
long enough for that?" 

When patients do take on the system, they can pay a
heavy price. Larry Hall came home the evening of Nov.
15, 2007, to find the equivalent of a "Dear John" letter
[17] from an attorney representing DaVita, his dialysis
provider. "Effective immediately," it said, "you will no
longer be treated" at Southeastern Dialysis of
Wilmington, N.C., where he had been a patient for more
than nine years. Enclosed "to aid you in finding a new
treatment facility," the attorney wrote, was a list of
non-DaVita facilities. The closest one was 50 miles
away, in South Carolina.

Hall had been dumped, or, in Medicare-ese,
"involuntarily discharged." A burly, soft-spoken man who
spent almost two decades as a uranium processor for
General Electric, Hall, 51, was a hyper-vigilant patient
who sometimes challenged clinic managers. Starting in
early 2006, they pressed Hall to sign a contract that
labeled him disruptive and required him not to "hand out
anti-DaVita or anti-dialysis literature on the
premises." Hall refused to sign and sued for negligence.
The discharge letter arrived a few months later.

A DaVita spokesman said in an e-mail that the company
did nothing improper and blamed the discharge on Hall's
"escalating disruption and behavioral issues." The
clinic continued treating Hall even after he sued, the
spokesman said, adding that while Hall later won a
$10,000 jury award for one claim, several others were
dropped. Hall was forced to seek treatment at the
emergency room of a nearby hospital, where he waited
hours for stations to open up and for tests to show that
his condition was dire enough to warrant intervention.
Once -- short of breath and swollen with 16 pounds of
excess fluid -- he says he was refused dialysis.
Hospital workers put him in a wheelchair and left him in
the lobby.

Regulators concluded that Southeastern Dialysis had
violated Medicare regulations by dismissing Hall without
advance notice. For now, Medicare officials have
arranged for Hall to receive dialysis at the hospital.
His treatments cost more than in-center care, and Hall
worries the plug could be pulled at any time. "I don't
know what's going to happen to me," he said. "I don't
have nowhere else to go."

The Italian Solution

Reggio Calabria is not the sort of town where you'd
expect to find world-beating health care. Dusty and
poor, it sits on Italy's southern tip, at the end of a
notorious highway that cost so much and took so long to
build that it became a national symbol of inefficiency
and corruption. The city's main public hospital has the
tired grubbiness of a bus station. Its unit for kidney
patients, however, typifies dialysis Italian-style.

Other countries provide universal access to dialysis
care, much like the United States. But some, notably
Italy, have better patient survival and cost control.
Italy has one of the lowest mortality rates for dialysis
care -- about one in nine patients dies each year,
compared with one in five here. Yet Italy spends about
one-third less than we do per patient.

These results reflect lower overall health care costs
and a patient population with lower rates of diabetes
and heart disease, but also important divergences in
policy and practice. "The differences in mortality are
staggering," said Dr. Daniel Batlle, who is a professor
at Northwestern University's Feinberg School of Medicine
and co-authored a 2009 paper on dialysis practices and
outcomes in Italy.

As Dr. Carmine Zoccali, slim and white-haired, weaves
through the 24-station outpatient unit in Reggio
Calabria, patients recline on beds, chatting quietly or
dozing. A doctor is present at every session, adjusting
treatments and handling any complications. This is
typical: A 2007 report [18] showed that Italian dialysis
patients had more than five times as much contact [19]
with their physicians as U.S. patients.

As Zoccali walks through the ward, nurses move between
the beds, monitoring patients' vital signs and
responding to the occasional bleat of a machine alarm.
There are no patient-care technicians, Zoccali explains,
and some regions set mandatory staffing minimums. His
unit has at least one nurse for every 3.5 patients.
Their expertise not only enhances safety, but also helps
keep patients compliant with their treatment programs,
Zoccali says. 

Most of his patients get three treatments a week, but
their sessions last at least four hours, more than the
U.S. average. Extending dialysis by 30 minutes per
session improves life expectancy, research shows, though
many patients resist adding time. Zoccali speaks
wistfully of a French clinic where patients get 12-hour
treatments and have lower levels of hypertension than
people with healthy kidneys. "The decision to make
dialysis faster wasn't a scientific decision, it was a
managerial decision," he says. "It's to allow you to do
four shifts a day and make money." He schedules just two
shifts a day to accommodate longer treatment times.

Zoccali and other doctors credit much of their success
to the Italian practice of sending patients to
specialists earlier than in the United States. There are
fewer financial barriers to such referrals. Those with
less-advanced kidney disease have equal coverage;
patients don't need to have reached kidney failure.
Intervening sooner "delays the need for dialysis and
reduces the number of patients," said Dr. Francesco
Locatelli, who oversees the nephrology and dialysis
program at the hospital in Lecco, near Milan.

Patients tend to start dialysis in better overall
health, he said, and more than 80 percent have fistulas,
the type of vascular access least vulnerable to
infection and clotting. In the United States, fistulas
have become more common, but most patients still start
out with catheters, often because they need dialysis
immediately and fistulas take time to mature.

The economics of dialysis are fundamentally different in
Italy, where public hospitals still provide more than
three-quarters of the care. Regional health authorities
pay more per treatment than Medicare -- roughly 50
percent more [20], the 2007 report found. But per-
patient costs are lower because Italy's indirect
expenses, particularly for hospitalization, are smaller
and because coverage includes drugs as well as dialysis.
A 2004 study found that Italian patients got half the
average dose of Epogen given to U.S. patients, perhaps
because there's no profit incentive to give them more.

Private operators have made inroads in Italy, especially
where local health authorities have faced budget
pressure. Areas with more private providers have so far
had outstanding patient outcomes, but some practitioners
think the statistics mask a more complex reality. "The
private centers do the simple things, but when they have
patients with complications, they send them to us," said
Dr. Giuseppe Remuzzi.

Remuzzi has presided over the dialysis unit in Bergamo,
an industrial city northeast of Milan, for more than
three decades. Poking his head into one treatment room,
he introduces four patients, all seniors, who have been
getting dialysis together for 17 years. A few doors
down, Gianni Bertoletti, 57, a wry, mustachioed man with
blue wire-rim glasses, is halfway through his session.
Bertoletti started coming to the unit in 1971. To
Remuzzi, their longevity is proof that Italy should
resist the U.S. dialysis model. "If we use the same
system you do," he said, "our patients will start to
have survival rates like yours."

Breaking the Chain

Despite the deep flaws in the U.S. dialysis system --
and the obvious ways that Washington could improve it --
big changes don't seem to be in the offing. Donald
Berwick, the new administrator of Medicare and Medicaid,
has not yet articulated his vision for the program, and
health care reform leaves it largely untouched. The
Institute for Healthcare Improvement [21], which Berwick
co-founded, has worked to promote the use of fistulas,
but a project director, Carol Beasley, has concluded
that a piecemeal approach to fixing dialysis won't work.
"It's unsatisfying to tinker with one broken part of a
broken system," she said. Berwick, whom conservatives
already accuse of supporting health care rationing, may
not have the capital to push a more holistic approach.

So far, he's taken the step of endorsing the
government's move toward payment reform. Starting next
year, Medicare will pay a combined rate -- about $230
per session, subsequently indexed for inflation -- for
treatments, drugs and other dialysis services, removing
the incentive for clinics to overuse drugs. The end-
stage-renal-disease program also will try for the first
time to tie pay to performance: Under a proposed rule
that takes effect in 2012, clinics could lose as much as
2 percent of their Medicare payments if they fail to
meet standards for anemia management and dialysis
adequacy, as measured by patients' blood tests. Dr.
Barry Straube, CMS's chief medical officer, called these
just the first steps toward addressing ongoing quality
issues in dialysis "in a serious and fairly rapid

Many industry experts doubt these changes will yield
much. For one thing, they offer no financial reward for
providers who deliver superior outcomes. Several
observers also said the government is making a crucial
mistake by rating performance by lab tests, not outcomes
or measures that reflect patients' quality of life.
"Mortality, morbidity, and infection -- that's the
bottom line," said Joseph Atkins, the former clinic
owner and consultant. "It's easy to adjust the labs.
What good is it if you have good numbers, but everyone's
dying or in the hospital?" 

Increasingly, patients, doctors and advocates say that
the way forward lies in focusing on alternative
therapies, particularly those, such as home dialysis,
that allow for longer and more frequent treatments. The
biggest potential gains may rely on keeping people off
dialysis in the first place. In that, the United States
is falling miserably short. The incidence of kidney
failure has increased by more than 80 percent since
1990; of the 40 countries that share data on this, only
Taiwan and parts of Mexico have higher rates. "The
centers are kind of the end of the line," Beasley said
of dialysis providers. "They could deliver perfect care,
but you still would be dealing with this tidal wave of
people" coming into treatment.

A potential bright spot in health care reform, she said,
is that extending better coverage to persistently under-
or uninsured Americans could lead to earlier
intervention for kidney disease. But as care expands and
the national health care debate staggers on, our four-
decade experiment with dialysis is worth bearing in
mind. All too often, patients get caught in a vise
between bureaucracy and the bottom line. As dialysis
shows, guaranteeing access can come at a steep price --
in dollars and in lives.

Lisa Schwartz, a researcher at ProPublica, and Guido
Romeo, a science writer in Milan, contributed to this


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