Sale of EMMC dialysis clinics stirs concerns about patient safety

BANGOR, Maine — The proposed sale of Eastern Maine Medical Center’s dialysis clinics to a for-profit corporation roused concerns Tuesday about the safety of patients seriously ill with kidney disease.

The hospital has signed a letter of intent with Colorado-based DaVita Inc., one of the country’s largest for-profit dialysis chains, to transfer ownership of its kidney dialysis clinics in Bangor, Ellsworth and Lincoln, as well as its home dialysis program. The deal also calls for DaVita to take over management of inpatient acute dialysis services at the hospital.

Dialysis is a procedure that involves filtering toxins from the blood of patients who have diseased kidneys. Many dialysis patients are older and suffering the effects of years of diabetes.

At a sometimes heated public hearing on the sale at Spectacular Event Center, a nurse’s union and patient advocates spoke out against the deal, concerned that DaVita will put profits ahead of patients and highjack local doctors’ decisions about patient care.

Officials with DaVita and EMMC, as well as some dialysis nurses who contradicted the union, argued that the company beats EMMC on many quality measures and has the expertise to better manage the clinics.

No patients of EMMC’s dialysis clinics testified at the hearing.

“When you assign a dollar value to each dialysis patient, you start down a certain path,” said Carl Ginsburg, an attorney for the National Nurses United union who has represented DaVita patients in cases against the company. “How will you recoup that investment? That has been the central concern of DaVita management from its inception.”

DaVita officials said the company’s clinical outcomes are among the best in the industry, leading to fewer infections and lower mortality rates. The company serves about 142,000 patients nationwide.

David Roer, a DaVita nephrologist and group medical director, said patient safety is a top priority for the company. The ownership change will leave decisions about patients’ care in the hands of their doctors, he said.

“The final decision is with the patient’s physician, it’s not made by a suit in Denver,” Roer said.

Tuesday’s hearing on DaVita’s application to buy the clinics was held under a state review process for health care projects known as certificate of need. A unit of the Department of Health and Human Services will review the application and recommend to the commissioner that it either be approved or denied. A preliminary recommendation is expected in August.

Neither the company nor EMMC have disclosed a sale price. A document submitted under the state review process states that the capital expense totals more than $10 million.

DaVita would purchase the clinics and EMMC’s home dialysis program under a subsidiary called Total Renal Care, Inc. It would assume management of the acute inpatient dialysis program at the hospital under a subsidiary called DVA Renal Healthcare and Patient Pathways.

DaVita’s purchase of the clinics would mark the company’s first foray into Maine. DaVita and competitor Fresenius Medical Care, which operates 10 clinics in Maine, run two-thirds of all dialysis clinics in the country.

Kathy Day, a patient advocate and registered nurse who formerly worked at EMMC, has spoken out against the sale, saying the loss of local control could put patients’ lives at risk.

Day became concerned about the deal after learning that DaVita, operator of more than 1,800 clinics in 43 states, is facing legal challenges on several fronts. Last week, the company settled a whistle-blower lawsuit over the use of an anemia drug for $55 million.

Day said she fears that if DaVita takes over the clinics, dialysis patients in northern Maine could be discharged against their will for complaining about substandard care and left with no other treatment options.

She highlighted the case of Larry Hall, a former DaVita patient in Wilmington, N.C. Hall had been a patient for nine years when he received a letter in November 2007 informing him that the facility would no longer treat him, “effective immediately,” because he had placed “extensive limitations” on the clinic’s staff.

The letter, from a DaVita attorney, included a list of clinics run by other companies where Hall could get treatment. The closest was more than 50 miles away.

Hall had challenged the clinic’s management about his care, saying poorly trained DaVita staff used the wrong needles on him, causing scarring and other complications that have required multiple surgeries to correct.

“It was like people off the street, not trained properly,” Hall said recently of the clinic’s staff. “They wanted to get patients in and out as fast as they could.”

Hall had sued the company for negligence and eventually won a $10,000 jury award. Federal regulators also found the clinic violated Medicare rules by dismissing him without notice.

For the last several years, Hall has received his dialysis treatments at the emergency room of a local hospital.

A DaVita spokesman said recently that federal privacy laws prevent the company from commenting on individual cases, but involuntary discharges are undertaken only when patient or staff safety is at risk. Because such dismissals are rare, the company doesn’t specifically track them, but they represent far less than one percent of DaVita’s total patient population, spokesman Vince Hancock said in a May 23 email.

DaVita was chosen as the best operator for the clinics after a lengthy due-diligence process, according to EMMC’s chief medical officer, Dr. James Raczek. If the sale is approved, the same doctors will oversee patients’ treatment and most of the clinics’ nurses have accepted job offers with DaVita, he said. DaVita will also operate under the same state and federal regulations as EMMC, he said.

Strict regulations and the highly specialized nature of dialysis programs have led most hospitals across the country to sell their outpatient clinics.

More than 80 percent of the nation’s 5,000 dialysis clinics are now for-profit, according to an analysis of the industry by journalism nonprofit ProPublica. Financial incentives encouraged for-profit operators to get into the dialysis game. The shift dates back to 1972, when Congress voted to extend Medicare coverage to nearly anyone diagnosed with kidney failure, including full payment for dialysis and kidney transplants.

Some nurses are worried that staffing ratios will be slashed at the clinics. The national nurses union and the Maine State Nurses Association organized a press conference opposing the sale ahead of Tuesday’s hearing.

A DaVita official said the company may in fact add staff to meet rising demand for dialysis services.

The application documents state that DaVita is interested in exploring opening a new outpatient dialysis clinic in Dover-Foxcroft and shifting more clinic patients to the home-dialysis program.

Sandi Hennig, a registered nurse and union member who works at the acute dialysis unit in the hospital, said DaVita is bound to have some patient complaints as one of the nation’s largest dialysis companies.

“You can pick any Fortune 500 company and find people who are unhappy with it,” she said during a break at the hearing. “You can find people at Eastern Maine who aren’t happy with the care.”

Many nurses who treat dialysis patients support the deal, encouraged that DaVita’s expertise and corporate resources will mean EMMC can upgrade old dialysis equipment and improve care, she said.

Dr. Michael McGoldrick, a nephrologist who treats EMMC dialysis patients, denied claims at the meeting that local doctors are cashing in on the DaVita deal. He and his physician partners will be compensated by DaVita under the same agreement they have with EMMC, he said.

“I stand to make zero dollars on this deal. My partners stand to make zero dollars on this deal. We essentially, using the expression, have no skin in the game. We are merely looking at what’s best for patients,” McGoldrick said.

Portions of DaVita’s April 11 application related to the allocation of the sale money, the fee arrangement between DaVita and EMMC for the inpatient program, and agreements for physicians overseeing the clinics were blacked out.

DHHS is accepting further public comments on the sale over the next 30 days.