By Peter Laird, MD
Davita made headline news in the Denver CO area recently over their business practices to include the use of higher than average EPO dosages that made their company millions of dollars. When I first started hemodialysis, even though I had a Hb level over 12, I was automatically started on EPO for a few weeks. I declined any further EPO after reviewing the medical literature on the risks and benefits of ESA use. This was back in 2007 prior to the release of the several studies which do show significant risks associated with ESA use including increased risk of MI, stroke, graft thrombosis not to speak of the increased cancer risks especially in patients with prior cancers who are now also on hemodialysis. Interestingly, my decision to stop EPO was not met with enthusiasm from my medical team. I was fortunate that within only a matter of weeks after stopping EPO, reports of adverse effects of this "wonder" drug stopped those criticisms of my decision short.
It turns out that my choice was prophetic. Nevertheless, despite several recent studies, the issues of increased cardiovascular events had already been duly noted even in the PDR prior to 2007 when the first of several reports arrived on the scene. In addition, I have survived cancer on two occasions fortunately by virtue of early detection at stages where surgery was completely curative, but for this reason, I have taken steps and precautions to avoid any further risks for cancer. My biggest reason for stopping EPO after about one month of therapy was the many articles showing worsening outcomes in the cancer patient population, a now confirmed link directly to EPO.
Davita stands today defending their documented practices of elevated dosages of EPO which earned their company millions of dollars under the old Medicare reimbursement practices for dialysis patients in the category called seperately billable items. At the height of their earnings Amgen's budget in the ESRD program accounted for nearly 40% of the total cost of the entire ESRD program and this fact alone led to the recently implemented Medicare Dialysis Bundle. Davita of all the companies evaluated does stand alone in the amount of EPO prescribed to its patients despite the known dangers of these drugs prior to 2007. However, Dr Allen Nissenson calls Davita's response to their documented EPO over usage transparent, but in my opinion, that is only if you consider that Davita has no clothes.
The king of EPO in my opinion, stands before us today naked with their greed based prescribing habits fully exposed. Many leaders of industry in similar circumstances caught with dirty hands turn to complete admission of errors and come clean before the public scrutiny that they cannot escape anyway. Davita on the other hand chooses to deflect and attribute their practices to excuses of different times and changing protocols for anemia management:
This is not a criticism of the team of reporters who worked hard on a complex, arcane subject that is a narrow part of the clinical care we provide. Your article suggested that we "continue to battle" controversies related to anemia management. In reality, those battles died a natural death in the media long ago.
I am the chief medical officer at DaVita, and prior to that was professor of medicine, director of the dialysis program and associate dean at the David Geffen School of Medicine at UCLA. Because the story could inappropriately alarm thousands of dialysis patients, and call into question the integrity of physicians across the country, we wanted to submit a few additional facts:
• Physicians make prescription decisions. Our affiliated physicians did what they felt was best for each patient every day. Every week. Period.
I would hope that all of the "loyal" Davita nephrologists realize that their CMO just sold them out and declares essentially that the dosages of EPO were simply as prescribed by the individual physicians involved and were not the result of corporate policies. Anyone who has followed the corporate policies of Davita against dissenting physicians who have left Davita understands the aggressive nature of this company against it's own who have left. Davita also continues the barbaric practice of re-use of artificial kidneys for purely monetary savings, any alleged benefits of re-use pales in comparison to the truth of it's dangers.
One of my favorite techs from my in-center days also worked at another privately owned dialysis clinic until shortly after they changed over to Davita leadership. Within a short period of time, the now Davita clinic reduced staffing levels to such dangerously low coverage that this tech quit her Davita job after in her opinion, being unable to care for her patients in a safe manner. Further, according to the tech, the patients in this unit often suffered at the hands of their prescriptions of dialysis with short dialysis times and high ultrafiltration rates leaving them nauseous, passing out and feeling completely drained. On Monday, Wednesday and Friday in the shared unit that I was in, this same tech observed those symptoms in a well dialyzed population with 4 hours average dialysis times only on rare occasions. The business practices between the Davita unit and the well run unit in her words were night and day. She no longer ethically could tolerate the Davita "difference" in that specific dialysis unit. She had called me in a bit of distress over the entire situation and left that employment at great financial cost to her family. The ProPublica series divulged dozens of stories equal to that and worse where staffing levels may have contributed to adverse outcomes, a shared trait especially among the for-profit dialysis chains.
I would urge Davita to own up to its aggressive prescribing habits and admit their mistakes instead of trying to offer platitudes of changing times and practices as their excuse in an attempt at transparency. The truth is that their practices netted them millions of dollars for their corporation in the separately billable portion of the old medicare payment system for dialysis but the real story I would like to know is how many thousands of patients might have suffered by these corporate practices at Davita. I would hope that the the Denver Post investigation does not end only in a series of investigational reports, it is time that the authorities question these practices as well. All just my own opinion on these investigational reports and Davita's responses to date.