by Gary Peterson
On Feb. 1, 2015 at the Annual Dialysis Conference in New Orleans, Canadian nephrologist Dr. Joanne Bargman gave a keynote speech entitled “Buffering the Numbers: The Decline and Fall of Dialysis Medicine.” According to Mark Neumann’s editorial from Nephrology News & Issues (NN&I), “Taken to the Woodshed… Again,” her talk ended with a standing ovation.
Both what Dr. Bargman told that audience and what Mr. Newmann wrote should sicken U.S. dialysis patients, Medicare officials, and our elected representatives. It is now evident, even at scientific meetings, how profit-oriented and cynical the U.S. dialysis care system has become. Not only is the U.S. continuing to trail the rest of the first-world countries in dialysis outcomes, cheating has become routine when reporting dialysis care data to the government. According to the NN&I article, Dr. Bargman’s U.S. colleagues tell her:
““We list our grafts as fistulas. No one checks it.” Lab tests are done repeatedly – before and after dialysis – to get the Kt/Vs that the staff need to meet the QIP requirements.”
This data is used to drive the reimbursement from the Medicare system under the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP).
For me, this fraud is not surprising. When Medicare began providing consumers quality data about dialysis facilities in 2001 under the Dialysis Facility Compare program, I immediately began receiving information similar to what Dr. Bargman is now hearing. Anonymous sources reported that blood test results were being “lost” when their values were outside normal ranges. No one, however, would go on record. Over the last ten years I have written periodically in news and opinion postings about my lack of faith in the Dialysis Facility Compare system and I often stated why I chose to ignore its results/findings.
Evidence of this fraud has been nearly impossible to produce. However, it became much easier to connect the dots this week. A new report, written by Alex Brill, was released by the healthcare law firm of Hooper, Lundy & Bookman. The (9-page pdf) report, “An Examination of CMS’s Dialysis Star-Rating System,” was funded by the Nonprofit Kidney Care Alliance. The report raises significant questions about the accuracy and validity of the Medicare’s Star Rating System, which is the new version of the Dialysis Facility Compare program. The report shows a strong correlation between the average household income in a locale/zipcode and the star rating of dialysis facilities in that locale/zipcode. Inadvertently, but in an incredibly timely fashion, this report provides insights regarding the disproportionate impact of certain quality metrics on the star ratings of different dialysis providers. I suggest that it also provides strong evidence of the fraud that Dr. Bargman described in her talk in New Orleans.
In his report, Brill examines the seven variables that make up star-rating system:
- Standardized hospitalization ratio (SHR)
- Standardized mortality ratio (SMR)
- Standardized transfusion ratio (STrR)
- Share of patients who had adequate Kt/V levels (that is, enough wastes removed from their blood during dialysis) (Kt/V)
- Share of adult patients who had hypercalcemia (that is, an average calcium level greater than 10.2 mg/d over the past three months) (Calcium)
- Share of adult patients who had a catheter (tube) left in a vein longer than 90 days for regular hemodialysis treatment (Catheter)
- Share of adult patients who received treatment through arteriovenous fistula (Fistula)
Table 6 reports the regression results, showing the effect of facility and demographic factors on these seven quality measures. It includes a breakdown by large dialysis provider and several other possible groupings.
Of these seven variables, two of them are highly susceptible to manipulation and fraudulent reporting: Kt/V (#4) and Fistula (#7). These are the same two variables mentioned by Dr. Bargman in her keynote address. Brill’s analysis reports that relative to other dialysis providers, DaVita achieves the best “performance” in these two categories. Kt/V and fistula results are contributing disproportionately to DaVita's star rating results.
The large dialysis providers, such as DaVita, own the laboratories that analyze their patients’ blood. They have complete control of the data, making manipulation easy and virtually untraceable.
We should thank Dr. Bargman for her willingness to confront this matter. She also has a history with DaVita. She appears in this video on the DaVita web site speaking at a 2012 DaVita meeting. According to a disclosure statement in a recent CJASN article, she is a consultant for Amgen, Baxter Healthcare, and Otsuka and has given talks for Amgen, Baxter Healthcare, and DaVita Healthcare Partners.
One company has shown a willingness to bend the rules that govern dialysis care again and again, paying huge settlement fees without ever admitting guilt. This pattern of corporate behavior puts other providers at a financial disadvantage. It is my hope that the HHS Inspector General and the U.S. Department of Justice will investigate this matter.