Medicare's Chief M.D. Speaks About Dialysis

[okarol]

November 9, 2010


Medicare's Chief M.D. Speaks About Dialysis

November 9, 2010
Listen to the Story [12 min 41 sec] http://www.npr.org/templates/story/story.php?storyId=131187340&ps=rs

A new yearlong joint investigation between The Atlantic and ProPublica has found many problems with dialysis in the U.S. The cost of treatment is among the world's highest, while the U.S. mortality rate for dialysis patients is one of the world's worst: One in four patients will die within 12 months of starting treatment. And striking problems were found in some dialysis facilities: unsanitary conditions, high rates of patient infections and few official inspections from Medicare, which offers comprehensive coverage to kidney failure patients in the U.S. and is supposed to inspect dialysis facilities once every three years.

Dr. Barry Straube is the director and chief medical officer for the Centers for Medicare and Medicaid, which has provided dialysis treatments, organ transplants and medical visit costs to any patient diagnosed with kidney failure in the United States since 1972. He joins Terry Gross today to respond to the criticisms present in the investigation published by The Atlantic and ProPublica. (The author of that report, Robin Fields, also appears on today's Fresh Air.)
More from today's Fresh Air
Man receiving dialysis
Health Care
Dialysis: An Experiment In Universal Health Care

"There definitely is truth in the fact that the [Center for Medicare and Medicaid Services] in its regulatory role, overseeing the quality of care in dialysis facilities, has not been able to perform as many surveys and therefore perform that type of oversight as well as it might like to have," Straube says. "We are hindered by funding that comes from Congress in order to perform regulatory oversight visits for all of the 17 different provider sites that CMS is charged with regulating. And the funding that is provided to the agency is insufficient in order to be able to meet the statutory requirements in terms of frequency and thoroughness of those sites."

Several years ago, Straube says, Congress told CMS to focus on annual visits to nursing homes, at the expense of other facilities, including dialysis centers, which were put on a lower-priority track.

"We have been not able to perform the oversight functions as frequently or as thoroughly as we might like to," he said.

But Straube says although Fields' investigation points to important issues, it overstates the degree of problems with dialysis centers in the real world.
Dr. Barry Straube
Enlarge Center for Medicare and Medicaid Services

Dr. Barry Straube is currently the chief medical officer at the Centers for Medicare and Medicaid Services.
Dr. Barry Straube
Center for Medicare and Medicaid Services

Dr. Barry Straube is currently the chief medical officer at the Centers for Medicare and Medicaid Services.

"When I read the article about an hour or two ago, it makes it sound like any dialysis unit that a patient walks into is subject to these problems, and that's simply not true," he says. "The vast, vast majority of the units are not as described in the several examples, which are completely true examples, but not illustrative of most dialysis units. ... That doesn't forgive our responsibility to try to identity those facilities that are not up to standards and then take whatever actions we can to make them better. My main quibble with the article is that it sounds like one would not want to have dialysis in the United States. This is a lifesaving treatment that the vast majority of people are being treated very well in very clean facilities that hopefully make very few mistakes."

Straube also talks about the lessons Medicare has learned from its 40-year dialysis experiment — and the ways in which the experiment might influence new debates on health care reform.

"[Paying for dialysis] was absolutely necessary because as Robin's article described, patients were dying before the onset of this program in the 1970s. There are some situations, as we proceed with health care reform, that we have to recognize without insurance being present — either generally or for specific conditions — people will die," he says. "I think the first thing that we need is having everybody have access to health care — not just in terms of having something close by but [by] having health insurance to be able to pay the bills to get health care that we all deserve. ... We have 25 million Americans with chronic kidney disease, estimated right now. That is many or more than patients who have diabetes in this country. And if we don't address those patients with chronic kidney disease, we are going to have many, many, many more ultimately requiring dialysis services."

Dr. Barry Straube is board certified in internal medicine and nephrology and is currently the chief medical officer for the Centers for Medicare and Medicaid. He also is the acting director of the Office of Clinical Standards and Quality.

[okarol]

From recent news: "Dr. Barry Straube is planning to retire from his position as chief medical officer at the Centers for Medicare & Medicaid Services on Jan. 31, 2011. Straube, a board-certified nephrologist, was the Medicare’s CMO for the last six years, as well as director of the CMS Office of Clinical Standards & Quality."

I never knew he was a nephrologist. What a sad state of affairs if even he could not improve the system from within.

[MooseMom]

I never knew he was a nephrologist. What a sad state of affairs if even he could not improve the system from within.

Perhaps if there had been more funding appropriated by Congress, he could have done more.  But oh no, we mustn't allow BIG BAD GOVERNMENT to actually spend money on dialysis oversight.  I wonder what would happen if Rand Paul and John Boehner ever had to go on dialysis.

So, the cost of dialysis in the US is the highest in the world yet the results are among the worst...and we have "the best health care in the world."  Really?  Really?

With the current political climate plus an ageing population plus more people suffering from CKD plus more people going on dialysis, NOTHING is going to get better for us any time soon. 

[kitkatz]

I worry about the time they are going to realize how damned expensive it is to keep us all on dialysis through Medicare and it gets cut off.  The government is going to realize what an elephant of bills they have created.  Be prepared for "pay or die" to comeback into play soon.

[Jie]

I am not sure that the u.s. healthare is the best in the world or not. What I know is that it is best work place to make money in the world... It seems a lot of U.S. health care professionals charge as high as possible.

[MooseMom]

I worry about the time they are going to realize how damned expensive it is to keep us all on dialysis through Medicare and it gets cut off.  The government is going to realize what an elephant of bills they have created.  Be prepared for "pay or die" to comeback into play soon.

It ain't gonna be before they realize that we should make sure that everyone has health care so that so many people won't end up on dialysis in the first place.  Hypertension and diabetes, we all know, are the main causes of kidney failure, and these are health issues that could easily be treated if everyone could afford any pre-dialysis care at all!  But no...we historically have this annoying tendency to address problems only after they've become so expensive due to short-sightedness.

[Scarlet]

I have to chime in here, and please I do not mean to offend, but....

I have heard via the US news shows that both Clinton and Obama were both pushing a universal health care plan but it died each time?  I don't understand why, is it due to the politics of the party's they belong too??  Are people really letting that get in the way of everyone getting health insurance??

Now understand that I do not in an way think that Canada's health care is all wine and roses, but I just have never understood when I keep hearing that "the American people want government to stay out of health care"  that it is better off as a private institution.....better fro whom?!?!

[cariad]

I worry about the time they are going to realize how damned expensive it is to keep us all on dialysis through Medicare and it gets cut off.  The government is going to realize what an elephant of bills they have created.  Be prepared for "pay or die" to comeback into play soon.

I just read that Obama is now negotiating with Republicans to cut Medicare and Social Security in exchange for 'curbing tax breaks'. No mention of letting the Bush tax cuts expire for the top 5% of the country.

http://www.bloomberg.com/news/2010-11-10/deficit-reduction-panel-s-plan-would-seek-to-cut-social-security-medicare.html

I am very disappointed in Obama. I do not think I could continue to support/defend him if he does this, but I will admit at the outset that I am very busy right now and did not read it carefully.

I saw on MSNBC (or maybe it was Colbert?) the other night that Truman reacted to congress switching control in the midterms by becoming "Give 'em Hell Harry" and that that really worked for him, he left office very popular. Republicans have made it so very clear that they have no interest in compromise, so I wish Obama would get a aggressive rather than negotiating with those people.

Anyhow, not enough time to go into any kind of depth on this topic now. I don't think we'll see a full return to pay or die, but it won't be pretty what happens to people closest to the financial edge.

Aaagh, Scarlet! I have so much to say on this but so little time. I hope to return, but 'better for whom' is a pitch perfect question to ask.

[MooseMom]

Scarlet, that's not an offensive question at all, but it IS a difficult one to answer.  Many years ago during a price and wage freeze, American business got around these restrictions by offering health care insurance to prospective employees as a perk.  It might have been a good solution at the time, but now, health insurance is a very expensive cost of doing business in this country.  It is very hard to dismantle a system that has become so incredibly complicated.

Health care in America brings big profits to large corporations.  No policitian wants to cross big business, and these corporations spend a lot of money to keep the status quo.  With the recent Citizens United judgment by our Supreme Court, money will now pour in to promote legislators who will protect their interests.

Americans abhor big government, and certain political parties have advanced the notion that universal health care means government controlled health care.  Our current administration didn't do more to promote universal health care because they did not think it would have the votes, so that is why they tried to get funding for a public option.  The idea was to allow people to keep their current insurance policies if they so wanted, but if they could not get insurance, then a public/government funded option would be available.  I wish I could tell you why this idea was so demonized, but I really don't have an explanation.

The cost of health care/services in this country is extraordinarily high, and I am not sure why (although if you read the ProPublica articles on dialysis that Okarol has posted, you might get some insight into this), but whether or not corporations or government foot the bill, the bill is very large indeed.  I guess people just are more comfortable with the devil they know, which is continuing to allow big insurance companies to control our access to health care.

[MooseMom]

Cariad, here's a link to a better explanation of what is happening...
http://www.huffingtonpost.com/2010/11/10/debt-commission-report-social-security-medicare-_n_781606.html

This is ONLY THE BEGINNING of the whole "what about this idea?" process.  NOTHING MORE!  Obama is overseas at the moment and is not commenting until the commission (which is bi-partisan, by the way) has completed their report and have made more recommendations. 

[Scarlet]

I know that this can be a very heated issue....

 In Canada at one time, your monthly health care cost was split between you and your employer, if you did not have an employer then the gov picked up their half.  If you could not afford to pay anything, and qualified, then the gov paid all of your cost...then at some point in the late 80's this all changed.

We had a new government that made promices to help out the tax payers by no longer requiring then to pay for any portion of the standard gov healthcare.....um...sure...OK.....thanks?

I can see how this plan assisted them in winning their election, but I feel that it set us on a course to a very bad place.  I and many of my friends and co workers did not think that it was an unreasonable system before the changes.  Yes there was fraud, but I can't believe that it was to the extent that it made more sense then chargeing the people that could afford it to pay a portion....

I am a Capitalist, I work hard for what I have, but I am also a Humanist and believe that we need to help our fellow man to thrive as well.  One of our local hospitals has started making noises about charging a Non-emergency fee, that if you go to Emerg for a sore throat or something non-life threatening they charge you $25.  If you are low income and can not afford it then you do not pay it.....again, I do not think that this is such a bad idea.

Sorry to prattle on, but after the hubby had to turn down his dream job in the US because I could not get/ afford private health insurance, and was told by the HR person in the company that the facilities for "public health" care can be somewhat 2nd world it has kind of stuck with me.....

I often think, but do not wish it, that all the people with "the power" would have one close relative with some major illness, maybe then they would "see the light"   

[MooseMom]

Scarlet, I think every society has to ask itself what do you do with people who are not able to look after themselves for whatever reason.  I think most people want to help those who are in need, but for some reason, the whole question of who is deserving and who is not clouds the issue.  Everyone seems to know of someone who has gamed the system, and this provides the excuse for not helping anyone.  If you're on Medicare or are receiving any sort of benefits, then you must be getting something you don't really deserve...that sort of thinking.  How we reconcile this with our self-image as a caring, compassionate and generous nation, I don't know.  And how we decide the criteria for who is deserving and who is not...well, you get into some pretty morally reprehensible rhetoric.

Injury and illness happen to us all, and I refuse to believe that there is no one in a position of power who understands what it means to be disabled.  Congresspeople and policymakers do not live in a vacuum; those that claim, for instance, that Obama "doesn't get it" forget that he has met more people in his life than you and I have put together, and I am confident that both he and many legislators know how devastating a chronic illness can be.  But people right now do not have much confidence in our fiscal health, and they are worried about their own finances and their own futures, and when people get frightened, they pull up the drawbridge.

I agree with you; I personally am not opposed to free health care at the point of service for those who cannot afford it otherwise.  I personally would rather my tax money go for that than for funding attack drones, and when there is an election, that's how I vote.  But again, there is an ever increasing number of people in these economically challenging times who are convinced that if you extend a helping hand to someone, the other hand is taking away from ME!

[Scarlet]

You are right MooseMom, people will always look to their own in times of hardship, and I can not fault them when that is essentially what I am doing here as well.

 I am holding my interest/needs before those of others and saying that mine are more important.  My husband always reminds me, lovingly, that I can be naive at times.  I tend to want the world to be better then it is, not that people don't care, but that we instinctively need to survive and that means taking care of what is our first.  I know that there are people out there that do think of others first, or many of the members of this very forum would not now be transplant recipients, and that gives me hope.