First Do No Harm ... to the Shareholders

[plugger]

First Do No Harm ... to the Shareholders
The Patient as Profit Center

By CARL GINSBURG

Nothing you are about to read will change at all no matter what Congress and the President finally agree to do in the never-ending circus of health care reform. A stratified system where privilege rules, and others wait, stays in place, unscathed. Primary doctors will not increase, nor will preventive care, nor will government assistance as envisioned by President Obama make a meaningful difference in the lives of anyone. Most doctors want nothing to do with Medicaid patients—indigent or otherwise. You see, in the end, doctors decide who they see.

They see dollars, lots of them. Take the example of the nation’s nephrologists – kidney specialists – who have made millions of dollars on patients in an on-going scandal of profiteering, ethical lapses and outrageous indifference.

In 1973, the US government stepped in on the side of patients suffering from End Stage Renal Disease—that’s when your kidneys stop doing the job. It’s an awful condition, often brought on by hypertension, diabetes and other illnesses related to the preventable stress and strain of modern living. Loss of kidney function occurs predominantly among poor, urban populations. The only way to stay alive, short of getting a new kidney, for which there are long waiting lists, is to go on kidney dialysis, a cumbersome process whereby a patient goes to clinic three times a week for 3-4 hours per session and has his blood cleaned mechanically.

Medicare picks up the tab for this life-saving process. In 2007, the government spent $8.6 billion for dialysis and with projections of kidney failure going up, patients on dialysis are expected to reach 400,000 in the next few years, money spent – and made – in this field is enormous and growing.

Health care is a profit center and it didn’t take a Harvard MBA – actually, a number of Harvard MBA’s did in fact run this scheme– very long to see the potential. Health entrepreneurs began approaching nephrologists across the country in the 1980s with offers to purchase their practices and many doctors happily agreed. With practices of 70-100 patients per doctor and Wall Street setting a price of about $70,000 per patient, nephrologists got checks in the $5 to $7 million dollar range. For what, exactly? For promising to send their patients to clinics now owned by for-profit clinic systems. And that wasn’t the end of it. Doctors also got directorships and other consulting deals for handing over their patients. Doctors just needed to agree to the protocols of the corporate dialysis company – the standing orders governing dialysis procedures and drugs. Remember, nothing in medicine gets done without a doctor’s prescription, so there needs to be enduring cooperation between the dialysis corporation and the MD.

As more and more nephrology practices were bought up, two players came to dominate the field—the DaVita Corporation, a Fortune 500 company based in Denver, and Fresenius Corporation, headquartered in Hamburg, Germany. Today, these two companies control more than 70 percent of the US dialysis market, making billions of dollars annually. The CEO of DaVita has banked hundreds of millions in bonus money. “We created this giant money machine that made a lot of nephrologists and entrepreneurs rich,” economist Stuart Altman told USA Today last month.

Making rich is doing right by shareholders, and nice for the nephrologists who sold their patients, but the reality is that dialysis in the US is the worst in the industrial world, with the highest death rates (21% of patients die each year, which means a dialysis patient lives five years on average) lowest quality and highest expense around. Across the board, from the hiring of unskilled technicians, re-use of equipment including the key dialyzer component, poor needle and other supply quality, machine repair, cleanliness, water preparation…. the for-profits brought the standards down. Patients who complain are summarily ejected from clinics, only to have Medicare cower when patients look to them for help.

Some doctors, actually just a relative few, backed out of the deals made to sell patients to the for profits, as they took offense at the substitution of their medical instructions for those of the corporation. Suits were filed, settled and sealed. Ah, American justice—not a peep.

And there is of course the pharmaceutical angle. One drug, epogen, a hormone that stimulates red-blood cell growth, has earned the Amgen Corporation billions of dollars since it was released in 1989. It is very expensive and very much in use in the dialysis field, where accusations of overuse are being investigated. No other industrial country uses such large dosages of epogen on its dialysis patients due to expense and concerns that too much can actually harm the dialysis patient. Epogen is the single largest drug cost for Medicare.

The only way to make sense of the US health care system, and to fashion some measure of meaningful reform, is to unravel the patient as profit center. Too bad the Administration didn’t get it right from the start.

Carl Ginsburg is a tv producer and journalist based in New York. He can be reached at carlginsburg@gmail.com

http://www.counterpunch.org/ginsburg09112009.html

[Stoday]

The danger to the profitability of the pharmaceutical companies is the possibility that Obama's proposals result in the eventual creation of a monopsony for medicines.

In the UK, the National Health Service effectivly runs a monopsony for the purchase of drugs. Drugs are listed provided they are effective and value for money. That keeps manufacturers on their toes; if the price is too high, they can't sell to the UK. Of course, some new drugs are too expensive and this causes some friction when patients who would be better off with the new drugs can't have them. That's the downside of screwing the lowest price from the manufacturer. However, such problems are rare; most new drugs are listed, perhaps at a price that's lower then elsewhere. That's the power of a monopsony. That's the force that drives the pharmaceutical companies to lobby against health reform in the US.

[nursewratchet]

Some of these points are valid, there is MUCH money to be made in dialisys.  With money and profit however, comes MANY clinics, as you say, every body is trying to make the money.  With that, comes more clinics, more choice for patients to go to whichever clinic they choose, and whatever part of the country they choose.  Able to vacation where they want because there are so many clinics.  Imagine having to drive MANY miles for treatment, or having to wait for treatments, because there were so few clinics.  If there were no profits, there would be far fewer clinics.  Every situation has a plus side to it.  By the way, Davita is NOT based in Denver, not sure where this guy got his facts.

[Meinuk]

Main corporate office

    * DaVita Inc.
      1627 Cole Blvd.
      Lakewood, CO 80401
      Phone: (303) 626-6000

http://www.davita.com/about/company/?id=937

[nursewratchet]

Main corporate office

    * DaVita Inc.
      1627 Cole Blvd.
      Lakewood, CO 80401
      Phone: (303) 626-6000

http://www.davita.com/about/company/?id=937

Not sure why it says "main corporate office".  There is an office there, but they are "home" is in ElSegundo, California.







Edited: Fixed quote tag error- kitkatz,Moderator

[Meinuk]

DaVita's website says that their main corporate office is in Colorado, because their main corporate office is in Colorado.  (Just outside of Denver)

http://www.colorado.gov/cs/Satellite/GovRitter/GOVR/1243429549778

OFFICE OF GOVERNOR BILL RITTER, JR
FOR IMMEDIATE RELEASE
WEDNESDAY, MAY 27, 2009


CONTACT:

Evan Dreyer, 720.350.8370, evan.dreyer@state.co.us


GOV. RITTER WELCOMES DAVITA HEADQUARTERS TO COLORADO


Gov. Bill Ritter issued the following statement today, joining Denver Mayor John Hickenlooper and economic development officials in welcoming the corporate headquarters for the Fortune 500 company DaVita to Colorado. DaVita will become the 12th Fortune 500 company to be based in Colorado, and the move could mean hundreds of new jobs coming to the state.


"While Colorado families and businesses continue to struggle, we are clearly seeing encouraging signs of economic activity -- and DaVita's decision to move its headquarters to Colorado tops the list," Gov. Ritter said. "Colorado's business-friendly climate and my administration's strategy to create new jobs, help businesses survive the downturn, and develop a highly skilled 21st century labor pool are positioning Colorado for a strong and sustainable recovery."


DaVita is a California-based leader in the kidney-care services industry. One of the main factors in DaVita's decision to relocate the company's operational headquarters to Colorado was the prospect of House Bill 09-1001, which Gov. Ritter signed into law earlier this month. The legislation, a cornerstone of Gov. Ritter's economic-development agenda this year, provides an incentive to companies that create 20 or more new jobs.


"On behalf of people throughout the state, we heartily welcome DaVita's Colorado expansion, and we congratulate Mayor Hickenlooper, the Metro Denver Economic Development Corp. and all of the other partners who helped make this a reality."

[nursewratchet]

My mistake.  they have always been in California, with pilot offices throughout the country, Colo. being one of them.  I didn't think the move to Colo. was final yet.  Sorry...

[plugger]

Speaking of DaVita, the Denver Post did an interesting story on them not too long ago:

http://www.denverpost.com/firstinthepost/ci_12830453

I did want to mention about the big for-profits and their takeover of the dialysis industry, I recall reading some USRDS stats that from '91 to '01 the number of patients doubled, but costs nearly tripled, and to boot deaths were up.  Wasn't that about the time the big for-profits were making their move?

[plugger]

www.usrds.org Annual Data Report 2003 pg 172, population up 106%, deaths up 123% from ’91 to ‘01

"In 1991 Medicare expenditures were $5.8 billion, and
non-Medicare costs from heath plans and other coverage were $2.2 billion—a total, then, of $8.0 billion from all sources (see Figure p.6 on page 17). By 2001, costs of the program had reached $22.8 billion, almost triple the earlier level of expenditures"
2003 USRDS Annual Data Report

[RightSide]

First Do No Harm ... to the Shareholders
The Patient as Profit Center

By CARL GINSBURG

. . . .
Making rich is doing right by shareholders, and nice for the nephrologists who sold their patients, but the reality is that dialysis in the US is the worst in the industrial world, with the highest death rates (21% of patients die each year, which means a dialysis patient lives five years on average) lowest quality and highest expense around. Across the board, from the hiring of unskilled technicians, re-use of equipment including the key dialyzer component, poor needle and other supply quality, machine repair, cleanliness, water preparation…. the for-profits brought the standards down.

http://www.counterpunch.org/ginsburg09112009.html

Yes, there are some quality control issues.

But that's not the main reason the death rate of hemodialysis is so high in the U.S.

To begin with, in countries like the United Kingdom, they just won't spend big bucks (or euros) on a patient whose life expectancy is low.  They have a standard of "Quality Adjusted Life Years."  And they just won't spend more than $40,000 to treat a patient whose QALY is less than a year.  Period.  The U.K.'s National Health Service has real "death panels."  So if these elderly patients are not treated by dialysis in their final year of life, their deaths don't show up in the U.K. statistics on dialysis.  They'll show up elsewhere.

Secondly, it was MEDICARE, not the for-profit sector, that set the U.S. standard of hemodialysis as 3 hours per day, 3x/week.  In other countries, the standard is much higher--and as you would expect, the life expectancy is higher.

Thirdly, America has a worse problem with obesity than other countries.  The health problems of obesity don't stop the day a patient is put on dialysis.  If the patient doesn't lose weight and get his cholesterol under control, those health problems will continue to take their toll, reducing the patient's life expectancy.

Bottom line: Every time you hear some pundit lamenting how other countries spend less on healthcare and get better outcomes, remember:  American society is unique.  In a number of ways.  For example, we have some "comorbid conditions" (like 30,000 automobile fatalities and over 20,000 gun deaths) that Great Britain just does not have.

[Zach]

Secondly, it was MEDICARE, not the for-profit sector, that set the U.S. standard of hemodialysis as 3 hours per day, 3x/week.

Sorry, but that is not completely true.

3 days a week, that is true. But 3 hours per day is not true at all.

It has been the sole decision of the nephrologist (and the center they work with) to cut hemodialysis treatment times--and theirs alone.  Medicare never set a 3 hour treatment standard.

At one point in the early 1990s, nephrologists raised the blood pump speed and cut the times down ... sometimes to 2.5 hours each treatment (X 3 days).  And death rates increased.

Countries in Europe and elsewhere give a minimum of four hours of treatment.   Many offering 4.5 and 5 hours.

As far as the U.S. is concerned, many non-profit centers in the U.S. have always provided 4 to 5 hours per treatment for their patients who should have it.

In this case, it is all about the money.

[Rerun]

I agree with everything except that kidney failure occurs mainly among the poor.  Not true.  It occurs among middle class and rich too.

I've known for a long time that I'm nothing but a mouse on a dialysis wheel.  I get to live so they can get rich. 

Making absurd amounts of money off sick people is just WRONG!

[KarenInWA]

I agree with everything except that kidney failure occurs mainly among the poor.  Not true.  It occurs among middle class and rich too.

I've known for a long time that I'm nothing but a mouse on a dialysis wheel.  I get to live so they can get rich. 

Making absurd amounts of money off sick people is just WRONG!

Amen, Rerun.  AMEN!!!

KarenInWA

[silverhead]

And how many kidney patients die from their disease, but are not among the statistics because the "official" cause of death was Congestive Heart Failure and they go on the "heart" list.....

[plugger]

I will add when you say 'Medicare' you might as well say 'Big Business'.  There is a term called board-swapping, that is when someone on a corporate board winds up in a government position and vica versa.  The example that comes to mind for me is a fellow named Thomas Scully - famous for being instrumental in bringing the 'donut hole' for senior citizens and prescription drugs.  We knew he was going to trouble when he moved from DaVita to just below the health secretary in government.  I recall he harassed one of our witness at the Senate 2000 hearings, but he did take good care of his big-money friends - think he is a lobbyist now.

[Stoday]

To begin with, in countries like the United Kingdom, they just won't spend big bucks (or euros) on a patient whose life expectancy is low.  They have a standard of "Quality Adjusted Life Years."  And they just won't spend more than $40,000 to treat a patient whose QALY is less than a year.  Period.  The U.K.'s National Health Service has real "death panels."  So if these elderly patients are not treated by dialysis in their final year of life, their deaths don't show up in the U.K. statistics on dialysis.  They'll show up elsewhere.

That is utter rubbish. You must have swallowed propaganda put about by the very organisations plugger is identifying.

Quality Adjusted Life Years is not a criterion for access to dialysis.
There are no "death panels"

The way of assessing if or when pallative care should replace dialysis is set out in detail in this publication: Click for pdf

[cariad]

Thirdly, America has a worse problem with obesity than other countries.  The health problems of obesity don't stop the day a patient is put on dialysis.  If the patient doesn't lose weight and get his cholesterol under control, those health problems will continue to take their toll, reducing the patient's life expectancy.

Who told you that America has a "worse problem with obesity" than other countries?

Australia World's Fattest Nation: http://www.news.com.au/story/0,23599,23890071-29277,00.html

Beyond that, you are conflating two different problems, obesity, which is mostly a cosmetic issue and is measured by the ridiculously random BMI scale, with high cholesterol, which can occur in people of any weight. Some people are meant to be heavier than others, just as some are meant to be taller than others. The rigid guidelines that are set by the government to divide people into categories tell us nothing about a person's health.

Stoday is right, there are no death panels in the UK. Are you serious? What do you mean when you say the UK does not have comorbid conditions like car crashes and fatal gunshot wounds (at the risk of nitpicking, 'comorbid' suggests an internal condition, not outside forces)? Are you suggesting that no one in the UK dies of gunshots or car crashes? Have you been there?

My mother-in-law is receiving expensive care for the elderly in the UK as we speak, and no one has suggested taking it away from her for any reason. These are dangerous, politically-motivated falsehoods.

[plugger]

It is amazing just the out-and-out lies being told.

Anyway, I did want to offer some hope that things are getting better - hate to always be a pill.  I did notice on the last advocacy DialysisEthics did for the patient in Texas it took us 1 1/2 weeks to get things settled; I'm hearing it has taken up to 1 1/2 years on some cases!  Also it has been encouraging to see some of this finally getting into the mainstream media - USA Today article.  We keep pushing and I'm sure there will be more to come!

However, I'm not sure I will ever rest easy while the for-profits are in charge - too many stories of good staff being run off, articles by some distinguished sources, and stats like I posted above.  Speaking of distinguished sources:

Dr. Belding Scribner is highly acknowledged as making a landmark invention - the Scribner shunt - that allowed access to dialysis for millions of people. Besides being a great inventor, you might include "prophet" to his resume:



“When Medicare began covering chronic dialysis in 1972, for-profit institutions sprung up to offer the treatment. Scribner turned down positions with these organizations, remembers Young. “Scribner took on the for-profits because he was first and foremost the patient’s advocate,” says Young. “He really loathed all of what he considered to be the abuse of the technology to make a big profit.” Scribner also became an advocate for more convenient and less costly home dialysis treatments, which he helped develop when a 16-year-old girl was rejected by the advisory committee. “
http://mednews.stanford.edu/stanmed/2003fa...d-memorial.html

“Scribner, who retired in 1990, created the first community dialysis unit, the Seattle Artificial Kidney Center, at Seattle's Swedish Hospital and was an advocate of non-profit dialysis centers.
"Although Belding Scribner is internationally renowned for his innovative clinical research, his motivation came from his role as a physician caring for patients," said Paul Ramsey, vice president for medical affairs and dean of the UW School of Medicine. "Countless people are alive today because of his pioneering innovation."
http://www.washington.edu/alumni/columns/s...s_scribner.html

“"Kidney dialysis today has become predominantly a for-profit business," said Joyce Jackson, current director of the Northwest Kidney Center. Watching the profit motive take over health care had been tremendously distressing to Dr. Scribner, Jackson said, and up until his last days he remained active in trying to expand public access to this life-saving treatment.
"The desire for profit in medicine and the desire by medical researchers to capture intellectual property disturbed him," agreed Larson.”
http://seattlepi.nwsource.com/local/127718...scribner21.html"

The links may have expired, but they are where I got the above quotes.