By Kris Robinson

How well do the nation’s dialysis facilities meet quality and clinical standards?  In November 2003, the General Accounting Office (GAO), Congress’s watchdog agency, reported serious shortcomings in Medicare’s oversight of dialysis facilities.  The report, entitled “Dialysis Facilities: Problems Remain in Ensuring Compliance with Medicare Quality Standards” (GAO-04-63), was requested by Senate Finance Committee Chairman Charles Grassley (R-IA).  Senator Grassley was the recipient of AAKP’s 2003 Congressional Leadership Award.  Although the GAO found most dialysis facilities meet Medicare’s quality standards, a substantial percentage did not - nor met important clinical practice guidelines.

Medicare supervises quality of care in every U.S. dialysis facility in two ways.  First, Medicare regulations list standards dialysis facilities must meet in order to receive payment.  These standards, known as “Conditions of Coverage,” were first established in 1976, and include facility management, patient rights and responsibilities and physical environment.  In addition, dialysis facilities report to Medicare data on certain clinical practice or treatment outcomes, including dialysis adequacy, anemia management and patient survival.  More information about both types of quality standards can be found on Medicare’s ESRD Web site at http://www.cms.gov/providers/esrd.asp.

In a Nov. 3 letter to Tommy Thompson, Secretary of the U.S. Department of Health and Human Services (HHS), and Thomas Scully, head of the Medicare program, Grassley stated he was “outraged by the lack of improvement in the quality of care being given to Medicare beneficiaries on dialysis.” Citing instances where facility staff did not respond to machine alarms or patient calls and other concerns, Grassley stated, “These patients go through enough and do not need anything more added to their situation.” A copy of Grassley’s letter is available online at the Senate Finance Committee Web site at http://finance.senate.gov/press/Gpress/2003/prg110603.pdf.

Following release of the GAO report, AAKP again called for creation of a “National Commission on Improved Kidney Patient Outcomes” - a request AAKP first made in October 2003 in a letter to Secretary Thompson.  As AAKP President Brenda Dyson said to the press, “Dialysis is a miracle for people whose kidneys have failed.  Quality must be job number one in providing dialysis - and as payor for 75 percent of the nation’s dialysis care, Medicare has a special responsibility. We call upon Secretary Thompson to create a national commission to address the quality concerns.”  

What were the specific problems GAO found? Here is a sample:

A substantial number of dialysis facilities do not achieve minimum patient outcomes specified in clinical practice guidelines.  Data from the Medicare Web site “Dialysis Facility Compare” (www.medicare.gov/ Dialysis/Home.asp), which provides important information on every dialysis facility in the United States, indicated in 2000, 512 facilities (among the over 4,000 dialysis facilities nationwide) had 20 percent or more of their patients receiving inadequate dialysis treatment - and nearly 1,700 facilities had 20 percent or more of their patients receiving inadequate care for anemia.

Problems that create potential for harm to patients include: (1) medication errors, (2) improper use of reusable dialysis equipment, (3) contamination of water used for dialysis and (4) insufficient professional medical involvement in the dialysis patients’ care.

Over the past five years (1998 - 2002), dialysis facility inspections found 15 percent of facilities surveyed had serious quality problems that, if left uncorrected, would warrant termination from the Medicare program.

The federal government delegates to each state responsibility for inspection of dialysis facilities without providing proper supervision.  Infrequent, poorly targeted and inadequate inspections allow dialysis facilities’ quality of care problems to go undetected or remain uncorrected.  For instance, only nine of 51 state survey agencies consistently met Medicare’s goal to inspect one-third of ESRD facilities annually.  And 216 facilities nationwide went nine or more years without any inspection!

The Medicare program has not taken steps to promote infoo rmation sharing between the ESRD Networks and state agencies on the performance of individual dialysis facilities. The complete GAO report is available on their Web site at www.gao.gov.  

What should be done to fix both problems in the operation of dialysis facilities and clinical treatment of kidney patients?  The GAO report recommends that the Medicare program (1) create incentives for dialysis facilities to comply with Medicare quality standards, (2) help inspectors identify and systematically document deficiencies and enhance monitoring and (3) provide additional assistance to state survey agencies.  GAO also recommended that Congress consider authorizing CMS to impose “intermediate sanctions,” such as financial penalties or denying payment for new Medicare patients, on dialysis facilities cited with serious uncorrected problems. 

Lastly, GAO recommended that Medicare provide to patients more information on specific facility survey results on the Dialysis Facility Compare Web site.  As GAO put it, “If ESRD patients were able to readily compare the outcomes of surveys for facilities in their area, they could choose to seek care from facilities with more favorable inspection results.”  In fact, Medicare already routinely posts such information on nursing homes on its Nursing Home Compare Web site.  

AAKP will, of course, continue to follow this story - and press for action!  Senator Grassley, in his letter to Secretary Thompson, demanded a detailed plan on how Medicare will address the problems uncovered by the GAO report.  AAKP will keep you posted!  

Kris Robinson is the AAKP Executive Director

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

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