The Question

Should outpatient dialysis clinics be required to have a physician, nurse practitioner or physician assistant on-site at all hours when patients are being treated, and should they be required to provide various clinic-related information to patients and the State?

The Situation

About 80,000 patients in California receive dialysis services from 650 Chronic Dialysis Clinics (CDCs).  CDCs are licensed by the California Department of Public Health using federal standards. To serve more patients, CDCs often operate 6 days a week for extended hours. Federal law requires clinics to report infections related to treatment. All patients have their own physicians whom they must see once per month. All clinics have a medical director who is a physician.

Two for-profit companies, DaVita Inc. from Colorado and Fresenius Medical Care from Germany, operate almost three-quarters of the CDCs in California.  The remaining CDCs are operated by a variety of nonprofit and for-profit entities.

Most patients on dialysis are covered by Medicare and/or Medi-Cal, which pay a fixed rate for CDC services.  About 10% of CDC patients are covered by group and individual health insurance plans. These plans often pay multiple times the amount for dialysis treatment than the amounts paid by government programs because their rates are negotiated with each insurance company. After a period of time all dialysis patients are covered by Medicare.

The Proposal

Proposition 29 would require that:

• A licensed physician, nurse practitioner or physician assistant, in each case with at least 6 months of experience in kidney care, must be on-site at all times when dialysis is being performed.  Telehealth may be used for up to one year if no such person is available on-site.
• Clinics report to patients the name of any physician with more than a 5% interest in the clinic.
• Clinics do not discriminate among patients based on their source of payment.
• Clinics report information about dialysis-related infections among their patients.
• Clinics obtain permission from the State to close or reduce hours.

Fiscal Effect:

There are fiscal implications for both the clinics and state and local government if this passes.  The clinics would probably have to pay hundreds of thousands of dollars more annually for staff salaries. State and local governments might have to pay tens of millions of dollars more annually if clinics close and patients must go to more expensive facilities such as emergency rooms, or if clinics negotiate higher reimbursement rates.

Supporters Say:

• Requiring a physician, nurse practitioner or physician assistant to be present during a dangerous procedure like dialysis, is common sense and a matter of patient safety.
• Dialysis clinics currently face fewer inspections than other health facilities and deficiencies are often uncovered.
• The big corporations operating dialysis clinics can easily make the required staffing changes and still profit hundreds of millions of dollars a year.

Opponents Say:

• Clinics already use specially trained technicians and every patient is under the care of their own kidney doctor, so more oversight is unnecessary.
• Prop 29 would take thousands of skilled medical staff from hospitals where they’re needed and place them in administrative jobs.
• On-site administrators who do not provide patient care would cost hundreds of millions every year, forcing clinics to reduce hours or close.