By William F. Owen, Jr., MD & Jay Wish, MD

Frequently Asked Questions about GAO-04-63, “Dialysis Facilities: Problems Remain in Ensuring Compliance with Medicare Quality Standards”

Do the findings in the GAO study apply to my dialysis unit?

The General Accounting Office (GAO) report was based on information obtained from dialysis units throughout the U.S. So, if your dialysis unit has been certified to care for Medicare patients (and most dialysis units are), your unit contributed information to this study.

If my dialysis unit contributed information, how can I tell if it was one of the problem units?

There is no simple way to determine if your dialysis unit was one mentioned as having problems. As reported by the GAO, most certified dialysis units in the U.S. are safe sites to receive dialysis care. Therefore, the odds are against your unit being one of the problem units.

Even if my dialysis unit was not mentioned in the report, how do I tell if problems exist where I dialyze?

Towards answering this important question, the starting point is to speak with your kidney doctor and/or the Medical Director (doctor in charge) of your dialysis unit.  These people who are critical in your care should be able to tell you when your dialysis unit was last inspected, what findings if any were made by the inspection team, the type of issues or concerns that were raised, how they have been managed to date and what approaches have been taken to keep problems from occurring in the future.

If you have Internet access, the answers to these questions can be supplemented by information available on the Dialysis Facility Compare Web site at www.medicare.gov/Dialysis/Home.asp. Dialysis Compare is a new initiative from the Centers for Medicare & Medicaid Services (CMS) that allows patients and their families to obtain information about how their dialysis unit is performing in several important areas of patient care. 

At present, Dialysis Facility Compare does not contain information about the results of inspections of dialysis units. If your questions are not answered completely by your doctors, an important resource is your regional End-Stage Renal Disease (ESRD) Network. The ESRD Networks provide information and advocacy (as needed) for concerns that you may have with your dialysis unit. AAKP maintains a contact list of all ESRD Networks or you can visit the Forum of ESRD Networks Web site at www.esrdnetworks.org.

I am fearful that if I ask too many probing questions or express my concerns, I may upset my caregivers.

Although conversations like those described may be uncomfortable for you, your dialysis care team is eager to learn your concerns and address them. Such conversations are best held in a quiet and relatively confidential setting, and answers to your questions will be provided as completely as possible. As a patient in your dialysis center, your views are important to making certain that optimal care is provided. Therefore, the dialysis care team will not be offended by your questions. In the rare circumstance that you have continued unease in speaking with your dialysis care team, your ESRD Network is a confidential and safe champion for you.

Are there signs that can tell me if my dialysis unit is unsafe?

Contrary to common knowledge, you cannot reliably look about your dialysis unit and tell the quality of the care. The size of a dialysis unit, the number of patients treated, the type of patients treated and the dialysis unit’s location are not predictive of the quality of patient care. Perhaps the best sign of the quality of your care is the responsiveness of the dialysis care team to your questions and concerns.

If you observe things in your dialysis unit that are confusing or upsetting, do not hesitate to discuss them with your doctor. Your doctor and other members of the dialysis care team need to understand your concerns so they can determine whether they relate to quality of care issues that need to be addressed. Many seemingly bad occurrences in dialysis units are related to the severe and complicated nature of kidney failure and the unfortunate limitations of dialysis treatments, rather than limitations in the quality of care.

The GAO report suggested that no one is really committed to overseeing the dialysis units. Are our elected officials, CMS and the states staying on top of these issues?

Since the previous GAO report of 2000, there have been many improvements in care for dialysis patients. However, as identified in the GAO report, there are still opportunities to further improve patient care and enhance the accountability of the dialysis providers. The GAO report underscores that the improvement of care for patients is not something that can be viewed as a completed task. Rather, quality improvement should be continuously monitored and better results for patients always sought.

In addition to continuing and expanding an important dialogue between people and agencies involved in the payment and care of dialysis patients, the GAO report offers several approaches that CMS may choose to incorporate in their oversight of the nation’s dialysis programs.  The report also describes some approaches that Congress may choose to pursue to help CMS and dialysis units improve patient care.

What are the next steps?

Senator Charles Grassley (R-IA), Chairman of the Senate Finance Committee and architect of this report, is currently engaged in a dialogue with the leader of CMS about the findings from the report. Moreover, CMS is continuing with several new initiatives to improve the frequency and quality of inspections of dialysis units. It is unclear if new federal laws will be passed to further strengthen these programs. For example, Congressman Pete Stark (D-CA), Subcommittee of Health, is working with leaders in the House and Senate to enact new federal laws to address some of the concerns raised by the GAO report.

What is AAKP’s participation in this matter?

AAKP shared its opinions and concerns publicly and privately with staff from Senator Grassley and Congressman Stark’s offices. Furthermore, AAKP wrote to Tom my Thompson, Secretary of the U.S. Department of Health and Human Services (HHS) requesting the formation of a “National Commission on Improved Kidney Patient Outcomes.” Of course, AAKP is a leading participant in the national dialogue about quality of patient care in the ESRD Program. Representatives from AAKP routinely engage with leaders at CMS concerning the current quality programs and the design of future programs. For further details, please contact the AAKP National Office at (800) 749-2257.

William F. Owen, Jr., MD, is Chief Scientist at Baxter, Renal and an Adjunct Professor of Medicine at Duke University, North Carolina. Jay Wish, MD, is Professor of Medicine in the Division of Nephrology at the University Hospital of Cleveland, Ohio.

The Dear Doctor column provides readers with an opportunity to submit renal related health questions to healthcare professionals who specialize in the area of concern. The answers are not to be construed as a diagnosis and therefore, altercations in current healthcare should not occur until the patient's physician is consulted.

This article originally appeared in the January 2004 issue of aakpRENALIFE Vol. 19, No. 4.

Back