Study Says Death Rate Is Higher for For-Profit Dialysis
Patients with kidney disease who are treated in for-profit dialysis centers are 20% more likely to die than those treated in nonprofit centers, according to a study to be published today in the New England Journal of Medicine.
In addition, patients treated in for-profit centers are 26% less likely to be referred for transplants, according to the study of 3,569 patients.
The report, which was met with skepticism by key dialysis organizations, including the National Kidney Foundation, is sure to further inflame debate over whether health care has become too profit-driven.
It could hardly come at a worse time for the for-profit dialysis industry, which serves two-thirds of the 200,000 Americans who regularly require the blood-cleansing treatment.
The $4-billion industry, which sharply disputes the report’s findings, is suffering tremendous financial strain as it struggles to shore up earnings and boost uniformly depressed stock prices after a period of rapid growth.
Dialysis, a life-prolonging treatment for people whose kidneys no longer function, is provided differently from most medical care and has come under tremendous scrutiny over the last decade. Most people undergo dialysis in outpatient clinics where, after 2 1/2 years, their care is paid for by the federal government. Each treatment costs about $130.
As in other areas of health care, there has been huge growth among for-profit dialysis clinics since the early 1990s. But the same factors that have spelled economic disaster for many hospitals, health plans and physician groups--too-rapid growth and overly optimistic earnings projections--have caused these highflying companies to crash as well.
“For-profit and not-for-profit health-care organizations may respond differently to financial pressures,” suggested Pushkal P. Garg, a Harvard Medical School physician and health policy expert who is the study’s lead author.
For example, he said, a for-profit center might cut staff as a way to improve the bottom line, and therefore have fewer personnel on hand to take care of the complex process of referring a patient for a kidney transplant.
The question of whether economic incentives lead to poor outcomes among dialysis patients is of particular interest in the United States, where the two leading causes of kidney failure--hypertension and diabetes--are increasing, especially among African Americans and Latinos. The U.S. has one of the highest mortality rates for patients with kidney failure.
In conducting the research, which was sponsored by the Robert Wood Johnson Clinical Scholars Program and Johns Hopkins University, Garg and his coauthors adjusted the data for several factors that could otherwise be tied to higher death rates from kidney failure, including the age, ethnicity and economic class of patients. They studied two groups of patients, one starting in 1990 and the other in 1993, from their first dialysis treatment until the end of the study in 1996.
They also separated dialysis facilities in hospitals out from the rest of the group, and focused strictly on free-standing centers. Then they adjusted the results again according to the federal guidelines for determining mortality in dialysis patients.
The results showed that while some for-profit centers had better results than some nonprofit centers, the overall national average indicated a 20% higher death rate among dialysis patients in the for-profit centers.
The differences were less apparent, however, when nonprofit and for-profit centers were located near each other, perhaps indicating that competition helps to standardize care, or that care is better overall in urban areas.
That sort of qualifying information, said some industry leaders, shows that it may not be correct to assume that the problem is one of for-profit versus nonprofit, or that referrals for transplants are an appropriate indicator of good care.
For example, a disproportionate number of rural hospitals are owned and operated by small groups of physicians, rather than large chains or academic teaching hospitals, said Kent Thiry, chief executive of Torrance-based Total Renal Care, the nation’s third-largest for-profit dialysis center operator. Because the rural clinics are isolated, it may be more difficult to refer patients for transplants, and it might also be difficult to obtain the sort of expert assistance that could ward off the early deaths of some patients.
In addition, Thiry said, one could just as easily argue that the clinics affiliated with academic teaching hospitals, most of which are nonprofit, have an incentive to refer too many people for transplants, since the hospitals will be paid well for performing the expensive procedure.
“It’s a little bit like taking data from auto fatalities before seat belts and using it for a discussion of auto fatalities after seat belts,” Thiry said.
Margaret Davis, director of the National Kidney Foundation’s Southern California operations, said that the study covers a period when the industry was indeed in need of improvement.
During the early 1990s, she and others said, there were few nationally recognized standards for dialysis care, and little monitoring of the many for-profit clinics that were springing up around the country.
Since then, however, both the industry and the federal government have launched initiatives aimed at improving the quality of care in the clinics, and have generally succeeded, Davis said.
“There have been changes in the field of dialysis even in the last four or five years,” Davis said. “Everyone has improved overall.”
Other examinations of the same data, she said, have not shown such significant differences in death rates at for-profit facilities.
Dr. Garabed Eknoyan, past president of the National Kidney Foundation who oversees its clinical practice guidelines, said that if Garg’s analysis is correct, the findings are “very disturbing.”
But, he said, he is skeptical that the findings represent an accurate picture of dialysis treatment.
“There is greater mortality in the United States than in other countries, and this is a significant problem,” Eknoyan said. “But it is over-simplistic to say that it’s profit as opposed to nonprofit. The issue is harder and more complex than that.”
Garg, the study’s author, insists that his intention is not to drive patients away from for-profit clinics, or to eliminate them.
Rather, he said, the results ought to be used to encourage the organizations that pay for dialysis--Medicare and health plans--to structure their economic incentives in such a way that clinics are prodded to improve results.
One way to do that, said Todd Richter, who analyzes the health-care industry for Banc of America Securities in New York, would be to pay clinics by the hour instead of in a lump sum.
“That way the incentive would be to leave the patient on the dialysis machine longer,” Richter said, thus providing a more thorough treatment.
Still, health policy experts said that the question of whether the quest for profit affects patient care is an important one.
Larry Levitt, a health-care analyst at the Kaiser Family Foundation in Menlo Park, Calif., said that previous studies have shown that many for-profit facilities, such as hospitals, have fewer employees per patient than their nonprofit counterparts.
Critics of for-profit care have long contended that those lower staffing ratios can lead to poorer patient care.
“The nonprofit organizations tend to be more fully staffed and tend to be more mission-driven,” Levitt said. “A for-profit organization is under pressure to make profits.”
