HemoDoc, From Doctor to Patient

The DaVita Difference: The Billing King

By Peter Laird, MD

Each month, Kaiser sends an explanation of benefits for my dialysis services. I see my dialysis team once a month, I do all of my inventory ordering, I perform all of my own medical treatments and I draw my own labs. My wife often wonders why she doesn't get paid to be my assistant since "we do all of the work." Her question is even more pointed when we saw the bill to Kaiser for August 2012 in the amount of $72,490.40.

In Australia and other nations, patients are given financial incentives to perform dialysis at home since it saves the health system tens of thousands of dollars every year. I am sure that is a non-starter politically here in America, but where can a dialysis provider supervising home hemodialysis patients only on a monthly basis have the audacity to generate such an outrageous bill? Indeed, my entire annual cost of dialysis and related medical costs is well below $72,000 each year.

At the same time, DaVita denies me enough supplies to last that one month period with one box of masks, 50 in each, which is less than needed for both my wife and I. One box of alcohol pads likewise fails to cover my monthly needs.  They further provide my dialysis needles on a one month basis compromising their integrity since they are not shipped in their original packaging of a box of 100. Did they use gloves and wash their hands before they placed them in a cardboard box not intended for this purpose and then shipped it to me through the mail system? Does this compromise my clean supply table every day as I attend my dialysis set up diligently in accordance to rules of sanitation?

Needless to say, Kaiser does not pay that bill in entirety due to contractual agreement. Yet for some health care providers, they do not have the ability to deny all of these claims which would total over $800,000.00 for a year of home hemodialysis treatment. With Kent Thiry publicly stating in a recent presentation that the business of DaVita is not about the patients, their greed and profiteering is evident each and every month when I obtain my explanation of benefits.

I understand that it is not about the patient each and every day that I fax my daily dialysis flow sheet so that the nurses at my unit can enter it into the DaVita billing system. Yes, DaVita is the king of dialysis billing. My impression of their entire system is that it is geared to billing much more so than to patient care. After all, Kent is right, it is not about the patient. That is the DaVita difference.

The DaVita Difference: The Transfusion King

By Peter Laird, MD

The major concern voiced about the renal bundle prior to implementation was withholding needed medications to maintain basic vital processes. The renal bundle is largely due to the abuse of EPO for the maintenance of hemoglobin levels in dialysis patients. Erythropoietin comes from health renal tissues that are absent in the majority of patients on hemodialysis with the exception of many with polycystic kidney disease. Under the renal bundle, EPO went from a separately billable income generator to a cost center for dialysis centers.

In the latest USRDS report noted by Gary Peterson on RenalWeb, blood transfusions increased throughout the industry, but the greatest increase is among patients at DaVita, a for-profit dialysis company.

"Since adoption of the bundled payment system, the number of transfusion events has increased, reaching 24 percent by September, 2011. Some providers are associated with a significant increase in transfusion rates over the one-year time period (the rate increased 46 percent in DaVita units), while others show minimal changes (4 and 7 percent in Fresenius and hospital-based units, respectively)."

Looking at further indicators of why DaVita has such an outrageous transfusion rate, one of the answers to that issue is not only in the 37% reduction of EPO use, but much more in their concomitant severe reduction of IV iron products by a factor of 42%.

Tracing the history of EPO abuse at DaVita leading to the moniker, the King of EPO, their gratuitous allegiance to profiteering, now evidenced by the 46% increased transfusion rate is nothing short of a shocking indictment of this company and their business plan. We all understood that the renal bundle would dramatically lower the usage of EPO, but the majority of practitioners expected an increased usage of IV iron products to maintain quality of life in dialysis patients.

Scott Rasgon at Kaiser Sunset maintained stable Hb levels with simple over the counter Vitamin D-3 supplementation while greatly reducing EPO usage. I have been fortunate to maintain my Hb levels with IV iron supplementation for nearly six years of dialysis to date. Patients understand well the quality of life issues associated with higher Hb levels. Sadly, there are absolutely no studies comparing the risk and benefits of EPO to the risk and benefits of transfusions.

Since transfusions are no longer allowed in many free standing dialysis units, hospitals and third party insurance companies pick up the tab on most of the transfusions that DaVita generated since implementing the bundle. This may make great business sense for DaVita generating further profits for their investors, but it makes no sense at all for the dialysis patients suffering with such severe anemia that they need such a large number of transfusions. As a practicing physician, I readily understood the risks of blood transfusions not the least of which is the risk of transmissible agents such as hepatitis and HIV. It was my goal to minimize the need for transfusions whenever possible.

Alan Nissenson has promoted the benefits of the DaVita model securing high quality of care as their model. In this instance, I must challenge their allegations of high quality care when they not only severely reduced EPO usage, but also withheld IV iron which is an effective and safe alternative and adjunctive therapy for renal associated anemia. I am sure that this has greatly increased DaVita profits, but at what expense to their patients.

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.