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01/03/2011

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MooseMom

I agree. I don't want to trust the compassion of the for-profit companies to provide me with best treatments. So how do we make the provision of individualized/optimal dialysis financially attractive to corporations? I think this is where companies like NxStage can find a lot of new customers. Home dialysis is a new marketplace with a lot of possibilities for profits. If we can get more people educated about home hemo, more companies would want to exploit this new consumer base. Demand increases supply. I think this is where we should start.

Francis

Regarding Moosemom comment (MooseMom | 01/03/2011 at 01:18 PM.
I must point out that this comment is contradictory. It asserts that companies cannot be trusted to provide for best patient interests and then suggest that a profit driven model offers a solution to poor patient care.
Established profit focused entities inherently work in opposition to “best care” as it usually entails greater expense. History over the 5 decades of evolving ESRD treatment show profits increasing along with sector consolidation as patient centered outcomes stagnate. This history is common with other industries showing a few large companies eventually dominate conferring great power to control future developments.
Home dialysis dramatically improves patient well-being vis-vis standard care and now has become a threat to monopolistic clinic networks and a few large drug companies. Obviously, great profits will be lost and these corporate leaders are seeking ways to minimize the loss.
Advancing to a patient centered treatment and enabling it to sustain over decades absolutely needs patient enlightenment and leadership to guide its evolution. Otherwise even if a new modality takes hold led by new companies, the ESRD industry sector will evolve similarly to our present system and manifest a similar clash of patient vs corporate interests and entitlements.
The long work by John Agar, MD and with Gary Peterson insights and publications are vital to the new opportunities of better patient care. Many doctors, nurses and others have worked persistently over decades to show these improvements though it was intuitively evident. You have delivered the message!!
We must grasp the solution now to this “unmet need”. Patients must understand options to mobilize and to take empowerment. Patients desperately need a unified voice to realize their entitled “best care”.

MooseMom

No, I don't think a profit-driven model offers a "solution", but perhaps it does offer "choice". If patients have more choice, then they will also have the opportunity for more education as they peruse their choices, and what we want above all is a more educated, enlightened dialysis community.

I'd love it if profit were not a part of the equation, but in the US, profit drives our society, so instead of wishing for something that's not going to happen, we need to find a way to incentivize innovation and then use the results to our advantage.

MooseMom

I have a general question and don't know where to post it. Regarding the rule that private insurance is primary for 30 months and Medicare becomes the primary layer after that...why 30 months? How was that figure arrived at? Has there ever been a put to extend that figure? Just curious.

Dori Schatell

Home dialysis is NOT a threat to dialysis providers, but it IS one to pharma companies. Dialysis providers benefit from having more folks at home, because:
-- Their staffing costs are lower
-- Medication use is lower (bad for big pharma)
-- More home (or otherwise better dialyzed) folks can keep their jobs and employer group health plans (EGHPs), which improves clinics' payer mix. They make more money from EGHPs than from Medicare.

We all need to stop perpetuating the myth that dialysis providers are barriers to home dialysis. They are allies!

roberta mikles

Dori, Indeed they might be allies NOW, due to bundling, however, before bundling things were much different. I use the facility my father went to as an example. Prior to bundling (announcement, finalized rule, etc.) there were NO posters in the lobby. However, all of a sudden, one day, as you walk in the lobby you are hit smack in the face with large posters, about six, on the wall. Staff were wearing buttons on their shirts that had to do with a contest ... who would come up with the best logo, statement, picture, etc., that would entice patients into doing home dialysis. I guess, call me naive, to some extent, but if providers knew, and they DID KNOW, that home is better, than why did they NOT push this before. I am sorry, but I just see this showing and saying 'oh before it did not matter to us whether you did home or not, but now we really, really want you to do home'. To me, this says alot.. of course, my opinion. I would have liked to have seen those posters from day one.
Roberta Mikles
Dialysis Patient Safety Advocate
www.qualitysafepatientcare.com

Dori Schatell

Not true, Roberta. They've been allies for years--or we would not have EVERY large and mid-sized (and some small) company sponsoring our Home Dialysis Central site--since 2004, well before the bundle.

I think you are reading far too much into the timing of whatever promo items they happened to launch.

roberta mikles

Dori, in all due respect, I understand what you are saying and that the dialysis providers have sponsored Home Central site, I just find it interesting that these posters were up as wallpaper at the same time of the bundling. For me, I guess, knowing home is better, my question is 'why did we not see this before?" Again, in all due respect, not sure I am reading into the 'timing' of such.
Roberta Mikles, BA RN
www.qualitysafepatientcare.com

Peter Laird, MD

Obviously the home dialysis market has a huge potential. It just so happens that this makes good business sense for the companies at the same time it serves dialysis patients best as well, perhaps 40 years too late for many, but nevertheless, it is a positive market force that we should align with.

Nevertheless, the issues with in-center must be addressed as well or we will in the end be no better than the nephrologists who would choose optimal dialysis at the same time they are denying it to their patients. A rising tide lifts all boats.

Dori Schatell

They haven't just supported the site, Roberta, they've also ALL put VPs in place to focus on home therapies, and that goes back several years as well. It takes TIME to turn a ship as large as some of the big providers. They basically have to get internal buy-in--sell the notion to their own staff and communicate new messages to huge numbers of people. They need to put new systems and policies and personnel in place.

The fact that a few posters went up recently doesn't mean that things haven't been starting to change since long before the bundle was even proposed.

Conspiracy theories and impugning the motives of dialysis providers is unfair, and will not get us where we need to be--which is, IMHO, patient-centered care provided using the Chronic Care Model ([url]http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2[/url]. This model would make education of dialyzors ESSENTIAL (we have the regulation now for this, but it will take time for it to filter into practice--especially without enough inspections!). That alone would go a long way toward improving care.

Peter Laird, MD

I think that lack of enforcement is the crux of the matter now. I did some research recently on all of the rehab programs available to dialysis patients as well as what the Conditions for Coverage 2008 spelled out realizing that CMS has already placed just about all that is needed if only they did what is written in the law. I came across a book on the subject detailing the involvement of MEI in the 2008 CFCs as well.

Inspections will be a touchy subject especially here in CA with our state essentially broke but in my opinion that is where the game is at right now on both a Federal and state level. That coupled with the market forces will go a long way.

We are still missing the incentives in-center to move them towards more frequent and longer duration dialysis which is the most important part of any program to improve activities of daily living for dialysis patients. There are many practices unique to America that need to be over turned and best practices generalized across the population. We are still a long way from getting all things in place. Thankfully the knowledge is complete in so many ways that we don't really need to debate much about optimal treatment modalities. The call for further studies will only be a delaying tactic that should be countered.

roberta mikles

Dori, I understand about the ‘internal buy -in’ of selling the notion to their staff, however, if staff are trained and educated, are they not aware that home is better, for many patients, considering each patient is an individual with individual needs? I would think, if they providers have been involved in this for several years, that we would have seen more movement towards home dialysis and more patients doing home dialysis than we are seeing now. And, in reality, you have to admit that it is more beneficial for providers now than before. I understand your position and for lack of better word, connection with the industry, and respect such. Perhaps, you are right that because a few posters went up things had not changed prior. I only know that which other patients in the unit had shared with me, especially, when I mentioned ‘home’. And, back to ‘selling the notion’… we hear more and more now that many would not want the 3x/week treatment that they give their patients, (staff and physicians).. So, I guess I am thinking that companies, if they really want to, they move fast with some things and not with others, e.g. that which you mentioned ‘sell the notion to their own staff, communicate new messages to huge numbers of ppl’.. Honestly, you have to believe in your heart that this could have been done already where more patients were at home doing their own dialysis.

If you are stating that I am impugning the motive of providers, that in itself is unfair. What I focus on is what patients tell me, what some staff tell me and what the survey findings state. Over the years, I have reached out to providers to share avenues they can travel to improve delivery of care, but no one wants to listen. Yes, I have been an outspoken patient advocate and an UNAPOLOGETIC one. Perhaps many have not read survey findings to see how patients are placed in potential negative outcome situations. When I hear providers not show any transparency and state ‘all is ok’ or ‘our outcomes are good’…. then I look at those facility survey findings.. I have to ask the question, “If a patient has great anemia management as the result of correct doses in the facility, but acquires an infection due to incorrect implemented infection control practices, or has the wrong dialyzer used, or the wrong bath and ends up in the hospital, etc. or bleeds to death because of lines disconnecting then outcomes are not good. Transparency and admitting there are problems and that they are working on fixing such and want suggestions is what many hospitals are doing. Providers are so fearful of being sued that they fear to admit a wrongdoing. I guess they are unaware that if they admit a mistake to a patient/family that the chances of being sued are decreased as was found after a study at one of the VA hospitals. Let me also add that I have, spoken with several providers and I do believe there are some individuals who truly care and have concern and want to make changes. I have also been made aware that many area/regional managers are not aware of certain things that happen on a day to day basis in their facilities.
Another example ---this is the recertification survey --http://www.qualitysafepatientcare.com/resources/2567%20Santa%20Barbara%20recert%202-2010.pdf


This was the 'first revisit' and still out of compliance...http://www.qualitysafepatientcare.com/resources/FMC%20SantaBarbaraDialysis%20REVISIT.pdf

I might add that according to DFC the facility outcomes were not bad...8% of patients had hemoglobins under 10 compared to 2% for state and 3% for national and their URR was 95% same as state percentage and one percent under national, although URR is not a good indicator. So fairly good outcomes, but many problems in the facility. And, as an added note.... The 'first revisit' apparently was just reviewed (read) in the state or CMS' office and there was no onsite visit... hence, how can we ensure the deficiencies were corrected? This is why surveys are so very, very important.
As always, the above are my opinions,
Roberta Mikles
Dialysis Patient Safety Advocate
www.qualitysafepatientcare.com

roberta mikles

Peter, agree with what you have said. The continuing problems related to delivery of care practices continues as noted in surveys, www.qualitysafepatientcare.com as well as those that have not been surveyed, according to the data Propublica released, as example,
http://www.qualitysafepatientcare.com/renal-care-partners-of-los-angeles.php http://www.qualitysafepatientcare.com/davita-atwater-dialysis-facility.php The system, or lack thereof related to oversight and enforcement is more than lacking as stated in many OIG reports. As far as the surveys you are correct. It is my opinion that it is CMS’ responsibility to ensure that each and every state has enough funding to ensure timely surveys. Afterall, CMS’ responsibility is to ensure Medicare beneficiaries receive quality safe care. Many states, e.g. Texas and Colorado, as I have mentioned have their own state-level oversight which helps. We hear providers want, as I have stated, over and over, their new facilities timely surveyed, but we never hear any of them fight to have their ‘existing’ ones timely surveyed. I ask the following question --- If a survey is conducted and there are numerous deficiencies that place patients in harm’s way, for example, http://www.qualitysafepatientcare.com/resources/2567%20Montclair%20recert%201-10-10.pdf The survey was conducted with some serious deficiencies. Should there have been appropriate unit-level supervision and/or staff being fully trained in facility policies/procedures with understanding rationale and consequences (patient related) for not implementing correct practices, would we have seen these deficiencies that placed patients in potential and/or harm’s way? Further, what is concerning is that it is obvious that management did NOT note these deficiencies, otherwise, the state would not have cited such. This is the part that is of great concern. Even with the flawed survey process, at various points, the survey still identifies that which the management level does not. This should be used as a tool and how a provider can state outcomes are good when such as this facility.. Well, just an example.

An example of Conditions, I am seeing, in Calif the same type of deficiencies being cited even after the NEW Condition and mandatory dialysis tech certification.

Roberta Mikles RN
Dialysis Patient Safety Advocate
www.qualitysafepatientcare.com

Dori Schatell

Roberta, far too many MDs have been waiting for the results of the FHN trials to really believe (or at least admit publicly) that there is a health benefit to more frequent HD--beyond just favorable patient selection. So, on the home HD front, that's probably what you're seeing. In-center nocturnal has been growing, too, and there are a few papers demonstrating its superiority over standard HD. PD--while beneficial in many ways--has comparable survival to standard in-center HD, so in the absence of strong champions at the individual clinic levels, its use has been dropping each year vs. standard in-center since the '80s, though the growth rate picked up about when we launched Home Dialysis Central.

There is a reason why dialysis clinics haven't been inspected as often as other healthcare institutions like nursing homes, hospitals, and mental health facilities. The same staff inspect them all--and the law requires annual inspections for the others. Dialysis gets the dregs--the surveyors' few moments when they're not inspecting something else they're legally required to. So, if anyone is interested in a legislative push, this would be a good area to focus on. Money is an issue, however. Who would pay for annual inspections, when they're done every 3-10 years now?

IMHO, standard in-center HD is outpatient institutionalization. Just because people can leave at the end of a treatment doesn't mean they're not essentially inmates while they're there...

Peter Laird, MD

Dori, with lack of inspection or enforcement, and lack of real informed consent, how will we interact to keep the industry from shunting people away from home hemo to home PD which is much cheaper and the most lucrative of the home programs for the industry, yet has the same but not better outcomes as in-center hemo which we all declare as unacceptable.

Home Nocturnal Hemo = Cadaveric transplant mortality.

Home PD = in-center hemo mortality which we are trying to improve.

If we have no inspections and no oversight of the actual informed consent process, I see in my mind that they will push for the home PD but that will not get us higher survival, only equal to the lousy survival we have today. I understand many people love the home PD over the in-center hemo or even home hemo, but no studies show it as good as the home, nocturnal hemo in outcomes.

How should we address this potential issue before it comes up as the next advocacy issue to address?

Peter Laird, MD

Dori, one more follow up question, if we are able to get in-center EOD or other increased frequency schedules, and we eliminate the 45% increased mortality on Mondays and Tuesdays, then in my mind, the home PD will become the most adverse survival strategy of them all.

Once again, I understand that people truly like the freedom of home PD, but if we actually get in-center hemo as good as it has the potential, we will be creating a new set of informed consent parameters for the entire ball game.

The logistics of changing the in-center schedule will be a difficult challenge to overcome even though the concept of EOD is so simple.

roberta mikles

Dialysis Facilities are not a priority with CMS and CMS thinks that because they have implemented the QIP that problems will be fixed, please... I would bet that those at CMS would not want to be in some of these facilities...Nursing homes are Tier 1 level so they are first priority and most of the revenue the state obtains from CMS is for nursing homes and that is why they ARE inspected every 18 months, at the lastest. If providers were seriously looking at how their patients are being delivered care, in my opinion, they would push for surveys and use these surveys as a tool for improvement because as we see in many CALIF surveys www.qualitysafepatientcare.com the facility was cited for not implementing their QAPI.. and this happened even before the NEW Conditions (facilities had a policy/procedure for QAPI). Sorry... but ..guess I am concerned about those who receive incenter care, not in all units, but in many.. I have shown, as above, what happens when facilities are not surveyed timely.
Roberta

Zach

@ roberta mikles:

Perhaps the "caring" folks at the Kidney Care Council and the Kidney Care Partners could chip in and provide the necessary funds for timely facility surveys and CQI.

Peter Laird, MD

Zach, you crack me up!!!

roberta mikles

Zach, nice to meet you, first.. Now, that I have stopped laughing... I know you are kidding, right? A bit of sarcasm, perhaps... Certainly if those two groups that you mentioned................well, am not going to go there. It is all so political and... well, again, we all know the story, don't we. All I have to say is I hope that none of those at KCC and KCP experience what some have experienced as evidenced in survey findings. There are so many that have ties, to varying degrees with the industry that it is really hard to effect change that is in the best interest of patients... for some things, that is.... So, should we ask those at the top of the food chain if they would want to experience such as in some facilities, or 3x/week dialysis, etc? Just wonder what they would say,, It just amazes me how no one provider has ever stated "inspect our facility to see if we are in compliance".. Sorry, but I just find such as not following facility policies and procedures to be a serious aspect of care.... Now, for yet another question... If a staff person is aware of correct practices, but does not implement such,,, is this staff intentionally placing patients in situations of potential or actual negative outcomes? This question is asked of my all the time. I wonder how many RNs in units have stopped to think that they have a 'license' and they need to protect it, e.g. making sure those they are overseeing are implementing the policies/procedures of the unit....
Roberta
www.qualitysafepatientcare.com
Roberta

Dori Schatell

Peter, there IS a place for PD. Keeping in mind that about 40% of folks with ESRD crash into the system emergently with <3 mo. warning, PD can be a GREAT 1st treatment. It's:
-- Easy to learn
-- Easy to do
-- Work-friendly
-- Needle free
-- Creates the expectation that the dialyzor will be in the driver's seat from the start
-- Allows time to get on the transplant list and/or get a fistula made for HD

DaVita had an abstract at the NKF meeting last spring claiming a 40% survival advantage for it--but they haven't yet published these data. Most folks who do PD are only able to for a couple of years (THAT'S what would keep providers from only doing it), but those couple of years can make all the difference between having folks who are ready and able to do self-care and those who are passive, in-center, and will stay there until they die (prematurely).

Once PD fails, folks who've been doing it become great candidates for home HD (so do folk with failed transplants). Make sense?

Roberta, clinics will never push for inspections. I'm afraid that will have to be a stick, not a carrot. It's possible that the ProPublica series has embarrassed CMS the the point that they'll free up $$ for more frequent inspections. We can only hope. I remember an IOM report a few years back that had similar findings re: frequency of inspections.

roberta mikles

Dori, you are right... and, my opinion is that CMS gives JCAHO the authority to inspect/reinspect hospitals in order to be accredited and re-accredited.. similar to that of CMS contracting with state survey agencies. Hospitals PAY to be inspected in order to stay open because Medicare, if I recall, will not pay, as will some insurance companies, unless hospitals are accredited by JCAHO.. So, perhaps the same for dialysis... I would hope, really HOPE that CMS is embarrassed. They spend money on all types of projects, etc .. consultants, etc.. but yet facilities are not being inspected. As I posted a few links to show what happens.. It is just a shame and I mean shame that these surveys show how patients are placed in compromised situations.. many time.. ofcourse, my opinions, but the surveys have a voice of their own. Providers give all types of reasons for deficiencies, but obvious, again my opinion... the lack of unit level supervision and thorough training.
Roberta
www.qualitysafepatientcare.com

Peter Laird, MD

Dori, I would hope all who call themselves patient advocates would agree that the lack of enforcement is the central issue missing in our fix dialysis equation. I would argue that enforcement of ALL regulations through inspection will shape up a dysfunctional, profit driven industry that at present has no checks and balance whatsoever. Simply tying in inspections for infection control to reviewing adherence to ALL of the Conditions of Coverage including rehab and informed consent is the bang for the buck that we are looking for.

I see no other approach that will work in my opinion. It is the missing link so to speak.

Peter Laird, MD

Zach, I have always wondered if you had ever considered doing a documentary on dialysis in America? If you would consider that, what would you look at and focus on in such a report. In fact, I truly would like to see your work on an issue so close to home for you.

Dori Schatell

NONE of the regs are enforced consistently without those inspections--not just the ones about things like safety and infection, but also the ones about educating folks, measuring health-related quality of life, and all the rest. Until the surveyors show up, some clinic staff don't even know what they're supposed to be doing.

So, this really may be the crux of a lot of issues, and is something we should focus on.

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