It is very infrequently that I side with the dialysis industry against patient initiatives to increase safety. Yet, that is the ironic position I find myself today in accord with both Fresenius and DaVita standing against CA Prop 23.
California Proposition 23, Dialysis Clinic Requirements Initiative (2020)
What would this ballot initiative require of dialysis clinics?
The ballot measure would require chronic dialysis clinics to:[1]
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- have a minimum of one licensed physician present at the clinic while patients are being treated, with an exception for when there is a bona fide shortage of physicians;
- report data on dialysis-related infections to the state health department and National Healthcare Safety Network (NHSN);
- require the principal officer of the clinic to certify under penalty of perjury that he or she is satisfied, after review, that the submitted report is accurate and complete; and
- provide a written notice to the state health department and obtain consent from the state health department before closing a chronic dialysis clinic.
The ballot measure would also state that a chronic dialysis clinic cannot "discriminate with respect to offering or providing care" nor "refuse to offer or to provide care, on the basis of who is responsible for paying for a patient's treatment."[1]
In an opinion journalism piece on Prop 23, Politico correctly characterizes this initiative as a ploy for forcing unionization in CA dialysis centers:
California's $100M dialysis battle comes with ancillary benefits for labor union
“The whole idea of using non-traditional tactics to achieve greater leverage in unionizing has been around for years,” SF State’s Logan said. “SEIU, in particular, is one of a number of unions that have used corporate campaigning very extensively and quite successfully over a number of years.”
SEIU-UHW, since 2012, has filed some 23 local and state initiatives. In recent years, they’ve launched a flurry of measures, targeting a number of California hospitals to limit prices and impose executive salary caps, though many failed to qualify or were abandoned.
While there are many clinical, political, ethical and legal issues that are unsettling in the dialysis arena, Prop 23 is not the fix for what ills this industry. It is of benefit only to the unions who are proposing these untenable restrictions and impositions. Obviously with a nationwide shortage of nephrology fellows in training, the provision of placing a physician on site while patients are in the treatment area is simply unnecessary, poor utilization of the limited nephrology providers and are simply a blackmail tactic on the part of SEIU to force unionization in dialysis centers. This would paradoxically decrees funds available for patient care given the fixed budgeting with Federal caps on Medicare payments under the Dialysis Bundle.
Further, even ICU's do not require on site physician coverage in the ICU itself. It is the well trained and very capable ICU nurses that are present at all times with doctors available by telephone 24 hours a day and backup coverage with physicians in the ER and hospitalists to assess and manage acute emergencies. Even here, an attending physician on site is not required or necessary. Dialysis patients are by and large much more stable on any given treatment day than ICU patients. Further, the regulatory requirements for crash carts in dialysis centers are remarkably deficient and do not have standard code medicines present in hospital crash carts or even clinic crash carts we had at Kaiser which were complete. Having a physician on hand in a dialysis center is even more absurd since they would have to wait for paramedics to arrive to have access to even basic ACLS medications used to abort common heart arrhythmias or treat acute myocardial infarctions. Doctors on site could provide no more advanced care than the nurses or technicians already on site.
In addition, health reporting mandates are already part of Medicare and state health guidelines.
I would urge dialysis patients in CA to vote NO on Prop 23 but continue to seek true reform and innovation in dialysis which is desperately needed in this industry. This is neither true reform nor innovation. It is exactly as Poltico correctly states, a ploy by these powerful unions to force the dialysis providers to the negotiation table.
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