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GAO finds evidence of quality problems at dialysis centers

Facilities say Medicare is underfunding care for patients with renal disease.

By Markian Hawryluk, amednews staff. Dec. 1, 2003.

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Washington -- A new report on facilities that treat people with end-stage renal disease has raised troubling concerns about the quality of care provided to the nation's dialysis patients.

The General Accounting Office found that in 2000, 512 U.S. dialysis facilities provided inadequate dialysis treatment for 20% or more of their patients, and nearly 1,700 centers provided inadequate anemia treatment for 20% or more of their patients. The GAO reports that there are roughly 4,000 ESRD facilities nationwide.

"A substantial number of dialysis facilities do not achieve the minimum patient outcomes specified in clinical practice guidelines for a significant proportion of their patients," the GAO stated.

Because ESRD patients qualify for Medicare regardless of age, oversight of dialysis facilities has generally fallen to the Centers for Medicare & Medicaid Services, which relies on state survey agencies for inspections. The report found that state inspectors cited ESRD facilities for serious quality problems on a regular basis. In fiscal years 1998 through 2002, 15% of surveys found quality problems so severe that without correction, facilities faced termination from Medicare.

Even when deficiencies were corrected, centers had little incentive to remain in compliance with quality standards. Over the five-year period, 18% of facilities with serious deficiencies were cited for the same problem in successive inspections, the GAO found.

While CMS has stated a goal of surveying 33% of ESRD facilities each year, performance has been inconsistent. In fiscal 2002, 216 facilities nationwide, or 5.4%, had gone nine or more years without an inspection, up from 53 facilities, or 1.6%, in fiscal 1998.

The GAO recommended that Congress authorize CMS to use immediate sanctions, such as monetary penalties or denial of payment for new Medicare patients, to force dialysis facilities into compliance.

The number of hemodialysis patients enrolled in Medicare has risen sharply, from about 118,000 in 1991 to more than 222,000 in 2000. The number of ESRD patients is expected to hit 520,000 by 2010, largely due to improvements in the survival rate and an increase in the number of Americans with conditions such as diabetes or high blood pressure that often lead to kidney failure.

Dialysis is generally provided in for-profit, freestanding facilities, more than two-thirds of which are controlled by four dialysis chains.

Centers blame low reimbursement

ESRD facilities counter that concerns identified by the report stemmed primarily from the low Medicare payment rates that make up 75% of dialysis funding.

"Medicare reimbursement is inadequate to allow the continued advancement of high-quality outcomes, pay for new technologies, and is clearly inadequate to recruit enough nurses and health care workers to work in the dialysis unit," said Larry Buckelew, CEO of Gambro Healthcare and chair of the Renal Leadership Council.

"Dialysis providers are the only Medicare provider without an annual inflation mechanism. We cannot compete for scarce nurses and other health workers with hospitals and other health care providers who have built-in inflation reimbursement increases," he added.

Instead, dialysis facilities rely on Congress to pass payment increases, and over the last 12 years, that has led to only a 3.6% rise in rates. Nursing salaries, by comparison, rose 27% on average between 1992 and 2002, Buckelew said.

Facilities also maintain that the GAO's findings did not take into account patients who are just beginning dialysis treatment. "A quarter or more of the patients each year are new to dialysis and have, on average, three other major co-morbidities," said Raymond Hakim, MD, chief medical officer for the Renal Care Group and chair of Kidney Care Partners, a coalition of 22 renal organizations. "Therefore, companies have to work very hard to provide the care needed to improve their quality outcomes."

The findings drew the ire of Sen. Charles Grassley (R, Iowa), who requested the report.

"I am outraged by the lack of improvement in the quality of care being given to Medicare beneficiaries on dialysis," he said in a statement on the report. "The oversight and enforcement of this industry is stuck in the stone age. Nursing homes are light years ahead of dialysis facilities."

Even before the report, CMS had implemented a number of initiatives aimed at improving dialysis care.

In June, Medicare officials announced a demonstration project that would pay dialysis centers bundled payments to cover dialysis as well as routine drugs and lab tests. Participating health plans would receive a capitated rate to provide all Medicare-covered services, including care not related to dialysis.

CMS also proposed a new payment system for physician oversight of dialysis patients that is to start Jan. 1, 2004. It would pay physicians according to the number of visits each month, instead of a set monthly fee. Physician groups have expressed concern that the new payment structure might not improve care and could hamper access for dialysis patients.

"Nephrologists may determine that providing services in outlying areas is no longer economically feasible because of the limited number of patients," said Norman Siegel, MD, president of the American Society of Nephrology.

The proposals focus exclusively on face-to-face intervention with patients without considering other dialysis care provided by the doctor, he said.

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