Don’t Believe Dialysis Industry Misinformation
July 2017
The dialysis industry’s biggest corporations have been spreading lies and misinformation about The Dialysis Patient Safety Act (SB 349), doing everything they can to prevent the bill from cutting into their huge profit margins by forcing them to invest more in patient care.
The fact is that the staffing ratios, minimum transition times between patients to reduce the spread of infection, and inspection requirements for chronic dialysis clinics called for in SB 349 are firmly rooted not only in common sense but a solid body of evidence from decades’ worth of peer-reviewed scientific studies.
Study after study in multiple hospitals, multiple countries, and multiple health care settings including nursing homes and dialysis clinics, show that staffing ratios and nurses’ workload—the number of patients assigned to each nurse—matter in terms of patient outcomes. In the dialysis setting, that specifically includes reducing the spread of infections—the number one cause of hospital admissions and second leading cause of death among dialysis patients.
Watch a video summarizing the major studies.
The basic argument is one of common sense. More nurses and direct caregivers per patient means more attention paid to that patient, which obviously means better and safer care. To argue the reverse, as the big dialysis companies do in opposing SB 349, would be equivalent to arguing that more police officers on the street would increase the danger of crime, that more firefighters would increase fire danger, and that more teachers per pupil would harm our children’s’ education. These arguments defy logic.
To suggest that having more registered nurses, more patient care technicians, more social workers and more registered dietitians, to attend to each and every chronic dialysis patient, will somehow hurt patient care, makes no sense. The argument is unjustifiable, there is no peer-reviewed scientific evidence to back it up, and it insults our basic intelligence.
The big dialysis companies’ talking points threaten three main consequences from the Dialysis Patient Safety Act, or SB 349, currently making its way through the California State Assembly after easily passing in the State Senate. They suggest that SB 349 would cause 20% of dialysis clinics to close, it would cut patient access to treatment, and patients would die as a result.
It’s not surprising that these enormously profitable big dialysis companies would make these arguments. They control 85% of the market and their profit margins stand to be reduced by the requirements this legislation would make for them to invest more of their outsized profits in direct patient care—bringing them more in line with major hospital chains in California.
Big corporations recycle these same forecasts of doom to discourage every effort to win staffing ratios in health care settings. The example most applicable is from 2007 and 2008 when the Centers for Medicare and Medicaid Services (CMS) decided to institute a requirement for one RN to be present on-site during dialysis treatments. CMS based this new requirement on research which showed that low RN staffing in dialysis clinics was significantly associated with tasks left undone and missed care for patients, which was in turn associated with adverse events, such as wrong medication given, hospital admissions and ER visits.
Watch a video about the research which inspired the CMS rule.
The big dialysis companies made all the same predictions about the CMS rule that they’re making now about SB 349—clinics would close, particularly in rural settings; nursing shortages would result; patients would be harmed. None of this happened. In fact, dialysis clinics have seen enormous growth since then, with more and more clinics opening all over the country, including in rural settings, with enormous profits flowing to the dialysis providers.
Anecdotal experience from a number of the other states which have passed caregiver ratios in dialysis indicate the same pattern. As the ratios were discussed in the state legislatures the big dialysis corporations mounted expensive propaganda campaigns predicting clinic closures and harm to patients. After the ratios passed, none of these forecasts of doom came to pass, and in fact, the dialysis business is booming. Dialysis services in states with ratios have expanded dramatically. Not only that, but the geographic dispersion of facilities has increased, as have services such as evening, nocturnal and in-home dialysis.
The two biggest for-profit dialysis companies, Fresenius and DaVita, control around 85% of the market. In 2016 their own tax filings showed that Fresenius had an operating income of $2.6 billion while DaVita made $1.9 billion. Fresenius had an operating margin of almost 15% while DaVita’s was nearly 13%. Contrast this with the average operating margins for major hospital chains in California, which go as low as 3% but not higher than 9%, and it’s clear that Fresenius and DaVita can well afford to invest more in direct patient care while remaining profitable and competitive.
One 2010 academic study found that patients had a 19% higher risk of death at Fresenius facilities and a 24% higher death risk at DaVita than at the biggest non-profit chain. Other studies show that mortality rates for in-center dialysis patients in the United States are among the worst in the world. Some studies have suggested that major dialysis providers’ lack of investment in personnel is one significant cause for the poor quality of care in the U.S. When all of these facts are considered, it’s apparent that SB 349 can not only help save the lives of dialysis patients in California, but in fact it’s vitally necessary and long overdue.
The major voices against SB 349 are the big dialysis corporations, along with industry groups largely funded by these companies, and vulnerable patients whose information about the bill comes from these companies. Like all for-profit corporations, they are under constant pressure to cut costs and increase shareholder profits. Meanwhile, there is significant evidence that these major dialysis providers have taken policy positions counter to the interests of their patients, and even acted fraudulently in ways that harmed patient health. Considering their domination of the market, the overall poor quality of U.S. dialysis is also an indictment of their credibility.
Those in favor of SB 349, on the other hand, are RNs and other dialysis health care professionals. Public polling year after year shows nurses to be the most trusted profession in America. That’s because the primary concern of nurses is their patients. Nurses are patient advocates, not just by calling but by the legal requirements of their licensure.
Balance the relative interests and reliability of the parties for and against this legislation and the decision should be easy—as it has been so far for the State Senators and Assembly members who’ve voted for the bill, after being lobbied by both the dialysis companies and direct patient caregivers. California led the country near the beginning of this century by passing legislation that set safe nurse-to-patient ratios in acute hospitals in our state. Hospitals and newspaper editorials made all the same arguments against that law at the time. Now there is widespread agreement, demonstrated in research going back decades, that such ratios improve patient safety and save lives.
History will side with SB 349, the Dialysis Patient Safety Act. It’s common sense, it’s backed up by research, and it’s supported by Registered Nurses and other health care professionals.
References:
Thomas-Hawkins C, Flynn L, Clarke SP. “Relationships Between Registered Nurse Staffing, Processes of Nursing Care, and Nurse-Reported Patient Outcomes in Chronic Hemodialysis Units.” Nephrology Nursing Journal: Journal of the American Nephrology Nurses’ Association. 2008;35(2):123-131.
Thomas-Hawkins, C. & Flynn, L. “Patient Safety Culture and Nurse-Reported Adverse Events in Outpatient Hemodialysis Units.” Research and Theory for Nursing Practices: An International Journal, Vol. 29, No. 1 2015
Wolfe, W. A. “Adequacy of dialysis clinic staffing and quality of care: a review of evidence and areas of needed research.” American Journal of Kidney Disease. 2011; 58(2): 166-176.
Wolfe, W. A. “Will We See Improvements in Providing a Safer Environment?” Nephrology News & Issues 2016;30(10):16,17, 40
Wolfe, W. “Is it possible to reduce hospital admissions through evidence-based staffing?” Journal of Nephrology News and Issues, July 6 2016
Foley, R, & Hakim, R. “Why is the Mortality of Dialysis Patients in the United States Much Higher than the Rest of the World?” Journal of the American Society of Nephrology 2009; 20: 1432–1435.
Robinson, B. M.D. et al., “World-wide, mortality is a high risk soon after initiation of hemodialysis.” Kidney Int. 2014 January; 85(1): 158–165.
Asci, G. et al. “Comparison of Turkish and US hemodialysis patient mortality rates: an observational cohort study.” Clinical Kidney Journal, 2016, vol. 9, no. 3, 476–480
Zhang Y, Cotter DJ. “The effects of dialysis chains on mortality among patients receiving hemodialysis.” Health Services Research Journal 2011 Jun;46(3):747-67.
Neuman, Mark E. “The largest dialysis providers in 2016: Poised for change.” (2016, August 12). Retrieved March 27, 2017, from http://www.nephrologynews.com/largest-dialysis-providers-2016-poised-change
Aiken, L. et al. “Hospital Nurse Staffing and Patient Mortality, Nurse Burn Out, and Job Dissatisfaction.” Journal of the American Medical Association. 2002;288(16):1987-1993
Aiken, L. et al. “Implications of the California Nurse Staffing Mandate for Other States.” Health Services Research, 2010;45(4), 904-921.
https://www.propublica.org/article/led-by-california-inspection-backlogs-weaken-dialysis-oversight
http://www.nephrologynews.com/with-cms-rule-out-who-will-protect-the-patients/
http://catalyst.nejm.org/the-big-business-of-dialysis-care/
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