Are DaVita Patients among the Village of the Damned?

By Peter Laird, MD

The Denver based magazine, 5280 published an expose on the CEO of DaVita, Kent Thiry called The Strangest Show on Earth. Luc Hatlestad spent several weeks embedded in the DaVita operation following the daily endeavors of Kent Thiry including his very controversial style of leadership at DaVita employee meetings.  He promotes the theme of the three musketeers in all of these meetings often entering in costumes in character shouting "all for one, one for all."

However, the shocking detail that patients fail to understand is that the DaVita "village" is only that of the employees and not the patients. The high fives create a culture of loyalty not to patients, but to the company. Kent Thiry has openly admitted that the business of DaVita is not about the patients. Many critics of DaVita understand these dynamics well:

DaVita has wider health care ambitions: patients wary

"I just don't see this ending well," said Bill Peckham, a Seattle dialysis patient who writes a blog popular in the kidney care field. "You're substituting business ethics for medical ethics, and I think that's a bad deal," said Peckham, who gets his dialysis from a nonprofit center.

Though the government is emphasizing its quality mandates in the ACO contracts it has issued so far, Peckham said the model encourages withholding of care to save money and create profit-sharing. DaVita faces legal challenges to its use of the critical dialysis drug Epogen, and to its business relationships with doctors.

Thiry calls himself "The Mayor," and employees "citizens" of the DaVita "Village," Peckham noted.

"Where does that leave the patients? We're the 'crop.' We're the 'ore' in the mines. That's not a fun place to be if you're the person who needs dialysis," he said.

Ironically, I am currently a DaVita patient on home hemodialysis after my DSI unit was taken over by DaVita. Already, there are major changes I have observed that leave me less than confident that my health care in this company is about me. I am tired of getting one roll of tape for an entire month of dialysis where I can easily use that one roll in a single session. I now must send in my clinic notes by fax on a daily basis once again, not for clinical oversight, but for billing purposes even though Kaiser only pays DaVita on a monthly basis.

DaVita further is in charge of my monthly labs. With their history of putting profits ahead of patient safety as evidenced by their alleged blind allegiance to increasing EPO dosages to maximize profits witnessed in recent legal actions against DaVita, I lack the personal confidence in DaVita to plaee my interests ahead of their own. After all, I am not part of their village, that belongs only to the employees.

One statistic that is difficult to document is the allegations of increased involuntary patient dismissals. For these unfortunate patients, speaking up against failings of the DaVita system in their own personal care often ends with an involuntary dismissal leaving some patients with no alternative units for their care. For these patients, life becomes a day by day struggle where the local emergency room is their only option. Unfortunately, most emergency units will only dialyze the patient if they are in immediate danger.  High potassium levels do not always earn them an intermittent dialysis session. Some ER doctors will give these patients a dose of Kayexolate to lower the potassium levels and send them home.  For these DaVita patients, an involuntary dismissal is tantamount to a death sentence leaving them truly in the village of the damned.

The Strangest Show on Earth

Some former patients have even accused DaVita of blackballing them to other non-DaVita dialysis clinics, which, if true, would be another federal privacy violation. “DaVita is number one in dumping patients,” says Arlene Mullin, an advocate in Battleground, Washington, who shared dozens of emails with me detailing alleged abuses of the patients she represents. She contends that DaVita clinics operate with virtually no accountability or oversight. “I’ve gotten notarized statements from patients so I can advocate for them, and neither ESRD Networks nor DaVita has recognized any of them. [ESRD Networks and the government] have no authority over these clinics. None.” Mullin claims that DaVita’s insider connections to CMS and ESRD Networks allow clinics to get tipped off about what should be surprise inspections. (She says this also happens at non-DaVita clinics.) The patient advocates I spoke with uniformly believe that ESRD Networks and CMS respond to grievances by stonewalling, burying them in bureaucracy, or ignoring them altogether. “Of all the patients I’ve helped to file complaints, in 100 percent of the cases, ESRD Networks has sided with the dialysis companies,” Mullin says. “Medicare has allowed this industry to oversee itself.”

Bill Peckham, a longtime dialysis patient turned activist blogger, goes a step further, saying the “all for one” DaVita Village concept simply doesn’t include patients. He likens the company to a village that mines coal. “We patients don’t have the voice of a citizenry; we’re just the coal.”

For anyone that understands that these kind of intermittent treatments place patients at high risk of death and other adverse outcomes, these patients truly are living in the village of the damned condemned to uncertainty, suffering and rapid decline in their health often imposing a sure death sentence. Sadly, DaVita is often the only dialysis unit in isolated communities leaving patients at the mercy of the DaVita business practices which by their own admission are not about the patients.

I suspect that my time at DaVita will be short lived and I am currently exploring other options for my long term care in the Pacific northwest area.  I have heard directly from DaVita employees who are uncomfortable with DaVita business practices and requirements. For a dialysis company to promote the village concept for their employees only but not for their patients leaves me with the same question that Bill Peckham has posed, where does that leave the patients?  For some of those that dared to stand up to DaVita and speak out, the involuntary dismissals that they earned truly leaves them in the village of the damned.

Comments

[Nancy Spaeth]

I agree with you, Peter. The first time that I met Kent Thiry, about 10 years ago, I watched his employee dog and pony show with all their rah-rahs and hand waving. I was disgusted then and still am today. As a corporation, their first legal obligation is to the stock holders, not the patients. It's so dishonorable, immoral and unethical!

[Peter Laird, MD]

I have only watched videos of these events and at first I thought it was some sort of joke or a skit about DaVita. When I realized it was for real, I couldn't quite believe it. It is very cult like in my opinion.

The real aspect is the all for one, one for all mantras can induce a culture of secrecy and protection when something goes wrong with a patient. One of my favorite dialysis techs gave up her DaVita job because she couldn't stand what was happening to the patients. She did this at great financial cost to her family who needed that second income. The last time my wife talked to her, she was in danger of losing her home, yet she never regretted leaving DaVita for one moment.

[Bill Peckham]

"For some people it’s just unacceptable that this model is profit-based. They’ll always attack us. They’re not evil people. It’s just that their ideology doesn’t allow for a virtuous for-profit company.”"

Peter isn't it a relief that Thiry doesn't consider us evil people! Point of fact though, I have nothing against profit. I do think it is to a dialyzor's advantage to receive care through a community based nonprofit dialysis provider but it isn't because of what happens to the revenues in excess of expenses.

The benefit of a nonprofit community based dialysis provider is that the structure invites engagement, as a dialyzor at a community based nonprofit you can have an impact on the care you receive. This engagement doesn't just mean there is a greater chance that you can have a unit that is a comfortable temperature, more importantly it means you can have a non infantilizing relationship with the business that provides your life sustaining medical care.

The impossible thing to convey to the urinator reporters that look into this dialysis business, is the corrosive effect of being in an unbalanced power relationship, of being powerless against the powerful, of literally having to cede the power to keep you alive, and then having the powerful, the unit, assert their power coercively. When the PTB decide that dialyzor conformity leads to greater profits, dialyzors will be expected to conform.

[Peter Laird, MD]

Bill, that really is the key to understanding life as a dialysis patient, lack of control. This is completely opposite to the rest of American medicine where informed consent to allow patients to control their own choices is in complete opposition to the experiences of a dialysis patient.

When I entered the arena of dialysis, I entered a world of control, retaliation and being labeled as a "difficult" patient simply for speaking out about different clinical issues.

That is also why I love home hemodialysis where I can once again regain control over my own life. Sadly, the majority of my interactions with dialysis nurses and technicians turns into a confrontational situation since I refuse to give up my control. Sadly, as a current DaVita patient on home hemodialysis, I am finding the love of money the guiding premise of my care. This is one example of where for profit medicine has gone horribly wrong.

No, it is not ideology for sure that unites DSEN and HemoDoc, it is indeed a recognition of the silenced voices of hundreds of thousands of patients threatened with certain death should they cry out against the business of dialysis and face an involuntary dismissal. I spoke out often and vocally, but I did so with an MD behind my name.

One patient told me that no one listened to her speaking the same things until I came along as a Kaiser physician. It shouldn't take an MD for dialysis personal to address basic human concerns in these dialysis units. Sadly, bloggers are the only voice speaking out against the business of dialysis. CMS, the ESRD networks have failed to over see the dialysis industry. No, we are not evil. That is perhaps the only thing that we will agree with Kent Thiry any time soon.

[Kathy Heffner]

Thx Peter...another great post..... Sadly things sound worst now than a few years ago.....

[Mike Carroll]

I thought if you were on home hemodialysis you wouldn't have a lot of interaction with DaVita, but that does not sound like that is the case. Why do you have to deal with them so much if you doing your dialysis at home?

[Chris]

5280: "Most dialysis techs are modestly educated and paid hourly; burnout and turnover are common." "Thiry knows his teammates’ jobs—essentially keeping people on life support for wages they could earn slinging Gorditas—can be intense and depressing, and his naturally sunny managerial tactics palpably boost morale"

I'm sure thiry's show makes up for the shortfalls when the techs are paying for their kid's education, groceries, and the mortgage. I know techs in 2006 were starting at $10 an hour! This while radiological techs were making a median of $22.77 an hour in 2006. http://www.dora.state.co.us/opr/archive/2006HemodialysisTechnicians.pdf I hope things have gotten better than six years ago, but it is sounding like not by much - plus they get to put up with the burnout and turnover.

[Peter Laird, MD]

Dear Mike, as a DaVita Home Hemodialysis patient, I am required to interact with the unit on a daily basis, something that I am not at all used to doing with other units where once a month is the norm.

DaVita supplies its patients with a fax machine and you have to send your daily dialysis sheets to the clinic. Since there is NO feedback from a clinical perspective, I must assume that this is for billing purposes which is what was implied to me when I asked.

In addition, DaVita has their own lab so that is where my labs go and they also have their own supply distributors. No, since DaVita took over my DSI unit, my daily interactions with DaVita have increased greatly.

[the Daily Medical Examiner]

Hi Peter, just found your blog by accident and have been enjoyed reading your posts... You have a unique inside perspective on patient life that most physicians will never understand. While no one would wish for such an opportunity, being able to see things from the other side of the bed would serve many of us well in our work. Thank you for sharing.

On a slightly related side note, I write a medical satire blog and have had several posts about nephrologists (not sure why they fascinate me, but I had several odd renal attendings back in residency). I hope that they will not seem offensive (the goal is to poke fun at doctors rather than patients...) If you find this in your comments and are interested, try "Dialysis Patient Admits He wasn't Taking Phosphate Binder." (http://medexaminer.wordpress.com/2012/06/23/dialysis-patient-admits-he-wasnt-taking-phosphate-binder/)

Thanks again for taking the time to put your perspective up on-line for the rest of us.

[the Daily Medical Examiner]

Oops! The link above got broken 2/2 the parenthesis.

http://medexaminer.wordpress.com/2012/06/23/dialysis-patient-admits-he-wasnt-taking-phosphate-binder/

[Roberta Mikles BA RN]

It is truly sad that patients don't come first and this is seen in alot of units, not Davita --However, the fact remains that Davita has problems and as I have always stated, what my late father stated "Is this the care you would want yourself or a loved one to receive?" I THINK NOT -- To get an idea of a Davita survey, we have posted a recent inspection report that went to the federal agency for review as I understand --- www.qualitysafepatientcare.com

Opinions of Roberta Mikles BA RN
Dialysis Patient Safety Advocate

[Christine]

I got fired from my contract at DaVita because I pointed out that our practices are about *US* and that we were self serving. I also pointed out lack of compliance that is supposed to make you lose your privilege as a CMS provider. I think the last straw was when I suggested the company seemed more like a cult than a business.

[Peter Laird, MD]

Dear Christine,

Sorry to hear of your ordeal with the "village." If you are not all for one, one for all, you become the enemy despite your stated conviction that you were seeking to improve care for the patient. Sadly, even Kent Thiry openly admits, "Its not about the patient." It's all about the team and the village. Not only is there no room in the village for the patients, apparently they don't want any dissenters as well. So, rah, rah rah, all for one, one for all. Yippee!!

[Peter Laird, MD]

Dear Roberta, I looked over the new report you posted on your website. I would strongly recommend patients at that unit look up the report and read what the inspectors found.

I would like to comment more, but this report on the Antelope Valley DaVita unit hits close to home. My home actually and I used to consult the nephrology group that runs this unit prior to DaVita buying their dialysis unit. I wish I could state more, but suffice it to let the report speak for itself.

Roberta deserves credit for the courage to confront publicly outlying dialysis units with poor reports. Roberta saw these issues with her own father. I am grateful that Roberta chose to continue her advocacy even after her elderly father passed away. I believe he is proud of your efforts Roberta and I know that there are many grateful patients thankful of your efforts.

God bless,

Peter

[Roberta Mikles BA RN]

Peter,
Your words are too kind -- As you know, due to some health issues, I had to decrease a good deal of my advocacy work for a while, however, decided to continue with the website --Although My father was not at a Davita unit (another LDO) he still experienced retaliation from staff, at times the physician and at times if I was not present he would have experienced negative outcomes --But, more important, his astuteness, his ability to be educated and understanding correct procedures, kept him safe during dialysis -- as he reminded staff of correct practices -
again, your words are very kind and I hope that this site gets to more patients so that they can read inspection (survey) reports -- I am hoping, shortly, to receive more surveys from the state for the first part of 2012--

[Lenore]

Both Fresenius and DaVita "cherry pick" patients leaving the hospital based units to care for those that are no "fit" for their outpatient units. Then Fresenius and DaVita promise these same hospitals that they will "manage" the care of these patients for them while making a profit

Disgusting!

[tz rn]

I found this blog entry because I am doing google searches on Davita as a prospective employer. I previously worked as an RN at another dialysis company and left after some very 'iffy' practices and frankly fear of losing my hard-earned nursing license because of this. The thing is, I really did love the patients and worked tirelessly to give them the best nursing service I could and this can be difficult when you are responsible for 12 at a time, 24 when the other nurse is taking her 5th smoke break. Alas, I really do like dialysis, I love the patients, I love the idea of life-sustaining technology. I have had relatives on dialysis and know how hard life is for them and their families. So after two years out, I'm thinking of returning. I am sorry that this is the experience so many patients have had, it makes my heart sad. With that said, please know that there are many of us out there who care about the patients, who care about their outcomes, because we want them to be well, not because of the bonus (which doesn't really trickle down to us). When I was in acutes, I would sometimes work up to 21 hours taking care of critically ill dialysis patients, praying (and I mean that literally) that they live through the night, and if they couldn't that they pass easily. I would umm, have 'lively discussions' with MDs about patients' meds and treatments, I've had to have security guards sit with me while dialyzing because the patients were violent, I've had to chase patients down the hall, because they were naked and a little crazy (but as soon as they had their dialysis, they stabilized), and have talked with the PCT's about speaking to me, the RN, before deciding on alternating tx based on sx (and worked with the PCTs with a team work mentality and we would discuss best options, I wouldn't dismiss their experienced and educated input). I advocated for my patients. I just hope your readers know that there are some of us out there that really do care about you, our patients, and we go into this work to make a difference -- despite the culture of the company. And...if I ever needed dialysis, I would also choose home care.

[mary]

Having been very recently aquired by davita , i feel for the patients.Please understand the staff that is actually giving you care is just as bewildered and frustrated as the patients. Our clinics before davita were patient oriented and thought was given to staff working conditions.From what ican seeis the only "villiage" perks are for the way high ups that do not dirty their hands with the real task at hand saving patients lives.

[Mary E]

Wow, I found these articles at a very opportune time. My Davita clinic is closing Thursday for training. When I asked what the training was about, I was initially told that the staff didnt know, that they were just told to be there. I continued to inquire about the training, and decided that I would like to go and asked the Dr. what I would need to do to be able to go. He told me to see the social worker. I did see her today and asked her about it. She stated is was HR stuff and I would not be interested. I told her I was very much interested, She stated that most of it was teamwork and that they had a slogan there were suppose to say/shout. Essentially I was told that I could not go. I asked her to call Davita and find out if I could go and if not, then why not. I really dont expect an answer. I found this site by trying to find someone to contact myself about this training. The training is called Academy II and is in Columbus, Ga. After reading several items about the potential fraud cases and the mindset of executives for this company, I want more than ever to attend. Thanks for your blogs and I will be following it more closely.

[Carolyn]

Most large companies do the same type of stuff. Of course it's not for the patients, it's to keep employees engaged, morale up and to provide extra courses/training. I'm not sure why patients are confused or feel like they should be involved in any companies training and meetings for their employees.

If you aren't happy with your clinic or your care speak up to the FA or switch clinics. All dialysis clinics have their pro and cons, find what works for you.

[Peter Laird, MD]

Dear Carolyn,

Most large companies do indeed offer training for their employees, but few if any do so in the manner of Kent Thiry and his off the wall antics. In addition, I don't believe that patients are the least bit confused about the very public fact that the DaVita Village does not include the patients. I myself found it quite shocking that the Davita Village concept excluded patients and then to hear Kent Thiry state publicly, it is not about the patients confirming my disbelief.

In addition, many patients do not have the free choice to move to other units should care fall below acceptable standards. With the ever growing consolidation of dialysis units, the issue of the DaVita Village which excludes patients I believe is the downfall of their business plan and the all for one, one for all concept further excludes patients should any errors occur. Who can argue that a nurse or technician would feel compelled to protect the company over the patient in situations where patients make complaints.

After nearly 20 years of internal medicine practice, the DaVita business concept of a village excluding the patient is completely foreign to my style of practice where I acted as an advocate for my patients and quite frequently was at odds in that action against my employer.

I took a great deal of heat from my superiors yet I did what I felt was in the best interest of the patient. In many ways however, I felt that was in the best interest of Kaiser in the long run as well. The DaVita training sessions make that natural human capacity to put the patient first behind their mottos to put the company first.

This presents a great dichotomy between the old fashioned virtue of patient advocacy FROM the provider himself vs the new DaVita method of promoting company loyalty all for one, one for all as the primary focus of their training. In such, I am quite opposed to their entire business philosophy.

[Irwin Jack Halpern]

Very intresting...........I've been informed that I will have to go into a Dialysis Program. After reading the above . I will have to seek other firms that perform the Dialysis Rx.
I have my doubts attaching myself to a "Machine" for the rest of my life. Any suggestiuon as to another firm would be appreciated.