In a damning series of investigative reports, ProPublica, in collaboration with The Atlantic, probed the question: Why does the U.S. spend more than almost any other country per dialysis patient and still have one of the highest mortality rates?
The question has dominated health headlines for days as the healthcare industry parses data from the ongoing investigation and subsequent news stories identifying serious failings at dialysis centers. One result of the report is that it highlights concerns about larger nephrology-related issues.
Physicians should recognize how important it is to institute measures to make widespread improvements in quality of care, Sharon Anderson, MD, president, American Society of Nephrology, said in an interview. ASN is currently working with CMS on a system of validated quality indicators designed to improve patient care, measure improvements, and provide consistent standards, she says.
Workforce issues may also play a role. "Many physicians will see this as further evidence of the crisis in the nephrology workforce: We do not have enough physicians trained in nephrology, and this shortage is projected to get much worse," she says.
An estimated 26 million people, 13 percent of the U.S. population, are living with chronic kidney disease, and this number continues to grow. If current trends continue, there won't be enough nephrologists, according to ASN data.
"Attracting more doctors to nephrology will go a long way toward improving care for all kidney patients. We hope one of the take-away messages is that kidney professionals need to encourage and mentor young people, to interest them in nephrology as a career," says Anderson.
So, was Anderson surprised at the results of the investigation? "Yes and no," she says. "With 26 million Americans suffering from kidney disease, it is a challenge to make sure all patients receive optimal care."
The ProPublica report offers a brief history of how dialysis is treated in the U.S. In 1972, Congress granted comprehensive coverage under Medicare to virtually anyone diagnosed with kidney failure. As a result, taxpayers spend more than $20 billion a year to care for those on dialysis—about $77,000 per patient, the report notes.
Nevertheless, the U.S. has one of the highest dialysis mortality rates in the industrialized world, according to ProPublica's findings: Approximately one in five dialysis patients dies—almost double the rate of European countries with the best outcomes.
If the U.S. system performed as well as Italy's, France's or Japan's, "thousands fewer patients would die each year," according to the report.
Investigators reviewed thousands of inspection reports, and interviewed more than 100 patients, advocates, doctors, policymakers, researchers, and industry experts. Critical to their investigation was previously unreleased CMS data—data CMS has now agreed to release, ProPublica reports.
The year-long investigation revealed "perilous lapses" in care, from unsanitary conditions to poor regulation, noting that U.S. regulators "have few tools and little will to enforce quality standards."
Why have these problems been allowed to happen? One reason, the report says, "is that kidney failure disproportionately afflicts minorities and the dispossessed."
The implications for health reform are strongly worded and dismaying: "As the United States moves to expand access to health care, dialysis offers potent lessons. Its story expresses the fears of both ends of the ideological spectrum about what can happen when the doors to care are thrown wide open: Neither government controls nor market forces have kept costs from ballooning or ensured the highest-quality care. Almost every key assumption about how the program would unfold has proved wrong."
The ProPublica series may be viewed here.