Illegal immigrants face life-or-death dialysis dilemmaSunday, November 16, 2008
DAVE PARKS
News staff writer
Luis Perez, 23, is living in a hospital Monday through Friday, and then checking out to spend weekends with his wife and 3-year-old child.
The unusual arrangement is the product of Perez's status as an undocumented immigrant desperately needing dialysis.
The treatment, which filters wastes normally removed by the kidneys, is usually delivered in outpatient centers. But Perez is unable to qualify for government assistance through Medicare that is routinely provided to U.S. citizens with renal failure. So as a last resort, he is getting dialysis at Cooper Green Mercy Hospital as an inpatient, a much more expensive level of care.
It's been going on for three months, and Perez is not alone. A rising number of undocumented immigrants needing dialysis are showing up in emergency rooms locally and nationally, authorities say.
"Every hospital in this county has had a patient like this," said Dr. Sandral Hullett, head of the Jefferson County-owned Cooper Green. "They come in through the emergency room. You have no option. What are you going to do - let the man die?"
Dr. Denyse Thornley-Brown, a nephrologist in charge of the renal clinic at Cooper Green, said outpatient dialysis centers are usually private, for-profit operations, and they are reluctant to accept indigent patients like Perez because they fear a rising tide of undocumented, uninsured immigrants with kidney failure.
"I think everybody is afraid there are so many patients they are going to lose money on these people," she said. "They've really not wanted to take them, and they've expected the hospitals to sponsor them."
Cooper Green and other hospitals have dialysis units, but they are licensed for inpatients, Thornley-Brown said. She knows of three other patients in Jefferson County who are in situations similar to Perez's, and she has other renal patients who are illegal immigrants facing eventual kidney failure. Latinos have high rates of diabetes, which causes kidney disease.
"I can see there are people coming down the pike," Thornley-Brown said. "This issue is not going to go away."
High impatient costs:
At first glance, denying routine dialysis to undocumented immigrants may seem frugal, but the only available alternative - recurring inpatient treatment on an emergency basis - is a far more expensive way of providing this life-sustaining care, according to recent research.
A study published last year by doctors at the Baylor College of Medicine in Houston compared two groups of undocumented immigrants with kidney failure.
One group was provided only emergency care, as required by the federal government. The other group was given routine dialysis and a level of care normally provided to U.S. citizens.
The result: The total cost of care for the group that went to the emergency room was 3.7 times higher than the group that received routine dialysis, the study found.
Cooper Green officials said it costs the hospital $4,480 a week to provide Perez inpatient treatment. Medicare pays less than $150 per outpatient dialysis treatment, meaning Perez's three weekly treatments would run less than $450 a week. Private insurance, however, pays more than that.
Ten states and the District of Columbia have extended Medicaid coverage to undocumented immigrants who need dialysis, said Cooper Green's Thornley-Brown. Those states are Arizona, California, Florida, Illinois, Maryland, Minnesota, New York, North Carolina, Virginia and Washington.
The Alabama Medicaid program generally considers dialysis to be a treatment for a chronic condition and not an emergency.
The federal government, which funnels money into Medicaid, requires that undocumented immigrants be denied routine care and limited to emergency treatment.
"We comply with federal law," said Robin Rawls, director of communication for the Alabama Medicaid Agency. "Conditions which require chronic treatment generally would not meet the requirement for emergency care. However, each case is reviewed based on the medical documentation submitted."
Thus, it's difficult to get reimbursement for inpatient or outpatient dialysis for patients such as Perez.
However, when his condition deteriorates, he qualifies for emergency treatment, said his attending physician, Dr. Alexandra Leigh. Hospitals are required by law to treat all emergency cases.
If Perez is discharged, he will deteriorate again, go back to the emergency room again and be saved again, only to start the process over.
"There's no safety net," Thornley-Brown said.
Child immigrant:
Perez said his parents brought him illegally into the United States from Mexico 18 years ago, when he was 5. He has lived like many undocumented immigrants, working long hours at jobs such as painting and housekeeping.
His health problems started about four months ago when he began sweating profusely and vomiting blood. He went to a private Birmingham-area hospital that, like all hospitals, is required by the federal government to treat anyone, including undocumented immigrants, for emergencies regardless of ability to pay. He was diagnosed with kidney failure, put on dialysis for a few days and discharged.
He was told to return to the emergency room if he needed further dialysis. He quickly deteriorated, but upon his return to the emergency room he was told that his condition wasn't an emergency, and he was refused treatment, Perez said.
Desperately ill, he went to Cooper Green. "I was in pretty bad shape," he said.
Leigh said Perez appears to have been struck by a hereditary condition that caused his kidneys to fail.
The doctor said she would much rather discharge Perez into an outpatient clinic, but that has been impossible. Perez needs dialysis to live, and discharging him could be fatal. "He would be dead within 10 days," Leigh said.
Dialysis dilemma:
When dialysis was fielded decades ago, it signaled a breakthrough in medicine, finally providing treatment for people whose kidneys had failed. But it also created an ethical dilemma: If patients could afford the treatment, they lived; if they couldn't, they died.
So the federal government stepped in during the 1970s, and now dialysis is paid for mostly by Medicare with some assistance from Medicaid and private insurers. More than 300,000 Americans are on dialysis at an annual cost of more than $15 billion, according to the U.S. Renal Data System. Lifetime medical costs for a dialysis patient easily can exceed $1 million.
Perez knows his treatment is expensive.
"They're spending a lot of money on me," he said recently, sitting on his hospital bed between walks up and down the hallway. But it would cost less if he got dialysis as an outpatient. Then he could be home with his family and work to pay some of his medical bills, although clearly he can't afford his treatments.
"I just started paying," he said. "I gave them $150."
Hullett said there is no way to get reimbursement for Perez's care. In the end, the expenses are absorbed by hospitals, and that raises health care costs in general.
"We take a hit as a hospital," she said.
E-mail: dparks@bhamnews.com
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