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Kidney punch

S.F. General is bracing for another round of service cuts – and patients who rely on the dialysis clinic may be the first victims.

By Tali Woodward

AFTER YEARS OF financial struggle, the kidney dialysis center run by UC San Francisco will likely shut its doors at the end of June.

More than 100 people stay alive because of the blood cleaning they receive at the clinic, which is housed at San Francisco General Hospital. Because other hospital-based dialysis centers in the city are full, staffers say, they are negotiating to place current patients at units run by DaVita, a publicly traded, for-profit company.

Health care professionals are not confident this is a good medical decision. Studies have raised questions about the quality of care at for-profit dialysis centers. And clinic staffers argue that the units lack a commitment to provide care to anyone who needs it – as well as access to the broad medical resources that the toughest cases sometimes require. They fear that some of the patients now dialyzed at S.F. General will end up with nowhere to go.

Still, hospital administrators say the financial realities – namely inadequate insurance reimbursements and the local budget squeeze – leave few alternatives.

"There aren't enough dialysis spots in San Francisco, and we're very worried about that," said Dr. Talmadge King, who oversees medical services at S.F. General for UCSF. "Closing our unit will definitely make matters worse. But we have to do it. We can't rob Peter to pay Paul. Both Peter and Paul are broke."

'We're the only unit in the city that takes the uninsured," clinic nurse Jennifer Gunn said.

Although all U.S. citizens who need dialysis are entitled to Medicare, many patients need treatment before they are enrolled. UCSF has always dialyzed those patients – as well as undocumented immigrants who are not eligible for Medicare but may get MediCal.

Health care workers say it's not likely that local for-profit units will do the same. Plus, they worry that some of the patients they care for will be discharged from DaVita clinics.

"Last week I got a call from the DaVita unit on Haight Street," said Dr. Rudy Rodriguez, the UCSF clinic's medical director. "They wanted to kick out one patient because he is an alcoholic and he smells like alcohol."

Patients on dialysis are hooked up two or three times a week to machines that effectively do the work of healthy kidneys – by removing waste from the bloodstream. Since clinics are only reimbursed for each treatment that is delivered, they have a reason to "cherry pick" patients who are most likely to show up for appointments, Rodriguez said. "When you're a for-profit unit and you have an empty chair, you're losing money," he said.

UCSF staff told us that patients are frequently discharged by for-profit clinics for missing as few as two appointments. "I'm concerned about those patients. There has to be a backup," said one staffer who asked to remain anonymous.

"I usually do not discharge people for missing appointments, but because they break all the rules," said Igal Koiman, the chief administrator at DaVita's Haight Street clinic. "We want to render services to people who want to be treated, not people who want to waste their time and our time. It has nothing to do with reimbursements."

Gunn also said that many of the UCSF clinic's patients have complex health problems. "They need to have access to the UCSF doctors and all the facilities at S.F. General." Stand-alone centers do not always have a physician on-site and tend to have more patients per nurse.

"There's no doctor at that private place – that's the problem. And I really don't like it," said Tony Chang, who has been going to the UCSF clinic for more than 10 years. "I also have a seizure problem, so it's good to be close to the hospital."

Irvin Quarles, who went to a DaVita unit a year and a half ago, told us, "I wasn't that crazy about it. Sometimes when you do hemodialysis, your blood pressure goes down, and it's very scary. I would much prefer being in a hospital setting where there are doctors." Quarles now goes to the UCSF clinic and said, "The service and attention I get there – money couldn't buy that."

"It's premature to be asking DaVita any questions about this," Joanne Otsuji, the operating vice president of DaVita's Sierra-Pacific division, told us. When asked if patients are discharged when they miss appointments, she said, "I know of no policy of that nature."

A little more than two years ago, hospital administrators announced a plan to sell the clinic to a partnership controlled by DaVita, then called Total Renal Care (TRC). The proposed deal included some equipment but was basically a sale of the clinic's patient list, which had the potential to generate hefty profits. Medicare currently pays about $144 for each two- to four-hour treatment.

Patients, doctors, and nurses protested – even traveling to Los Angeles meetings of the UC Regents to register their disapproval (see "Kidney Center to Be Sold to Private Firm," 12/1/99). The patients' case was bolstered by a study published in the New England Journal of Medicine Nov. 25, 1999. The study found that patients who go to for-profit dialysis centers are less likely to get on transplant lists and more likely to die while on dialysis than those treated at nonprofit facilities.

The sale fell apart – but not because of concerns about for-profit dialysis.

TRC became embroiled in a series of company problems. In February 1999 investors filed a class-action suit, which the company eventually agreed to pay $25 million to settle, while denying all wrongdoing. TRC was investigated in Florida for overbilling Medicare by more than $15 million at one of its labs and, elsewhere, for allegedly paying doctors to refer patients to its clinics, according to documents on the company's Web site.

TRC restructured and changed its name to DaVita. According to its Web site, the company now treats 41,000 patients at 486 dialysis facilities across the country.

In the meantime, dialysis "has gotten so expensive, you can't give away a renal center," clinic director Rodriguez said. In particular, the prices for drugs that dialysis patients take have gone up.

"Payments remain the same, and all the costs are going up – so we have been worried for years," UCSF's King said. "We have managed to maintain [the dialysis clinic] at a break-even point, but our projections are that it will begin to lose more money."

According to UCSF administrators, a unit must serve at least some patients who have private insurance in order to survive. But privately insured patients don't want to go to the run-down UCSF clinic, which has already been forced, because of space shortages, to send more than 50 patients to the for-profit units.

"To keep the clinic open, we would need to get more money from Medicare or MediCal and also some kick-in from the city or the university," Rodriguez said.

He's not the only one suggesting that the city pick up the slack.

San Francisco health commissioner Arthur Jackson, who was on dialysis for six years before he received a kidney transplant, said the city needs to continue providing dialysis, even if it means incorporating a new clinic into plans to rebuild Laguna Honda Hospital: "If it is at all possible, the long-term plan is to find a home for that dialysis unit."

King estimates that it would cost the city about $1 million a year to run a dialysis unit on its own. Care providers throughout the city say such an investment might prevent bigger bills that patients who don't get dialyzed are sure to generate.

"My concern is that we're going to see patients who should be at home," said Dr. Teresa Palmer, who works at Laguna Honda. "The patients with psychosocial problems or the ones who may not be on time – the General can just roll with it, but a for-profit place won't."

King acknowledged many benefits to offering dialysis at S.F. General but said that his hands are tied. "Now, if a specific program doesn't pay for itself, it's cut," he said. "We probably will have to make more decisions like this as the year goes on."

E-mail Tali Woodward at tali@sfbg.com.