An announcement on May 27 by the Health and Hospitals Corporation that the sale of dialysis patient services and equipment at four HHC facilities was “postponed indefinitely” was greeted with cheers by NYSNA nurses, their patients and supporters. The four HHC hospitals – Kings County, Harlem, Metropolitan and Lincoln – will continue to provide chronic dialysis services to patients.
The decision is a resounding win for quality standards, skilled nursing and the public hospital system. Efforts by a for-profit provider, Big Apple Dialysis, to take over those HHC clinics have been sidelined. With this victory, NYSNA has helped establish a line against outsourcing in this sector of essential care. NYSNA is determined to hold that line.
HHC reaffirmed in its announcement that quality care was its top priority. Outsourcing to for-profit companies, however, remains on HHC’s agenda, as part of a budget plan to reduce costs. But NYSNA will continue to guard against outsourcing, including in all areas of dialysis, that sacrifices quality care and undercuts services at the public hospitals.
In the end, the facts won out.
Comparisons of two critical measurements of patient outcomes – mortality and hospitalization – came down on the side of the HHC facilities by substantial margins. The 12 facilities of Big Apple Dialysis in the New York City area have mortality outcomes that are 35% worse than the four HHC clinics. On rates of hospitalization Big Apple Dialysis was found to be 11% worse than HHC.
Nurses and patients join together
In launching and sustaining this successful campaign, NYSNA was joined by dialysis patients and community advocates, by other unions and public health professionals. Patients and NYSNA members appeared and testified at hearings before state and city officials, sought support from the Mayor’s office, from Public Advocate Tish James, and from the City Council, notably Health Committee Chair Corey Johnson. The support of all was forthcoming.
Dialysis clinics are required, as a matter of law, to report mortality, hospitalization and other outcomes to Medicare and these data are accessible to the public. Medicare characterizes poor care in chronic dialysis by the designation “worse than expected”. (“Expected” takes into account factors of age, race, gender and condition of patient upon first dialysis treatment.) In the U.S. overall, about 9% of clinics perform very poorly – at the “worse than expected” level. For New York State, as a whole, 10% were “worse than expected”. Big Apple Dialysis’ record showed more than 41% of its clinics at “worse than expected” levels. None (0%) of the HHC clinics is rated “worse than expected” in mortality.
HHC care better
Similarly, on rates of hospitalization, Big Apple Dialysis achieved “worse than expected” levels in 25% of its facilities. HHC clinics had none (0%) at this poorest care level.
That means that no HHC dialysis patient runs the risk of being cared for in a “worse than expected”-rated dialysis clinic. “HHC has a fine record of care provided to dialysis patients at its four facilities,” testified Anne Bové, RN, Bellevue Hospital Center nurse and president of NYSNA’s HHC Executive Council. “We, at NYSNA, are proud of that record.”
Threat to patient safety of for-profit
The data presented by NYSNA in behalf of retaining the dialysis clinics within the HHC system was reviewed by Dr. David Himmelstein, an internist, professor of public health at City University of New York and lecturer at Harvard Medical School. “I endorse the disturbing conclusions regarding quality and outcomes of chronic dialysis at Big Apple’s clinics presented by the New York State Nurses Association,” wrote Himmelstein. “[I]n my judgment the proposed transfer of patients from HHC to Big Apple Dialysis poses a serious threat to patient safety.”
The backbone of quality at a dialysis clinic is its nursing staff, for whom making patient assessments and adjustments in the course of treatment of End Stage Renal Disease patients is a fine-tuned skill and key to quality care. Big Apple Dialysis proposed to cut RN staffing by more than half in its submission to the New York State Department of Health to affect the transfer of patient services. While no nurse would have lost a job had the Big Apple Dialysis deal gone forward – RN positions at units other than dialysis were promised – the prospect of no longer providing care in the dialysis setting was very disturbing to NYSNA RNs. Patients voiced their concerns too, in rallies in New York City and in Albany, in testimony and letters.
Big Apple scrutinized
Earlier this year, NYSNA RN David Quarshie, who works the chronic dialysis clinic at Harlem Hospital – one of the units targeted for sale – testified at a hearing before the City Council Committee on Health Oversight. “It is critical to safe and effective dialysis to have RNs treat chronic dialysis patients, because patients can become unstable very quickly, as most of our patients have other co-morbidities, such as diabetes, hypertension and coronary issues,” Quarshie told the Committee.
Big Apple Dialysis continues to operate acute dialysis facilities in a number of HHC hospitals. These are service contracts for the staffing and management of in-hospital dialysis assessment and care. Undoubtedly, there will be calls that the acute facilities be scrutinized. Accounts are surfacing of substandard care at the acute dialysis units run by Big Apple Dialysis.
Beginning in the mid-1990s, chronic dialysis services were targeted by Wall Street as a profit center, as Medicare payments, supplemented by substantial profits from anemia and other medicines, presented an enormous revenue opportunity. Through aggressive merger and acquisition activity, two for-profit companies are now in control of more than 80% of the U.S. chronic dialysis market. Together, the two generated $26 billion in revenue last year. CEO salaries and stock options are through the roof in an industry where average dialysis patient lifespans are only five years.
Non-profits have better outcomes
The very unfortunate reality is that profits have been linked to higher death rates in the chronic dialysis field for some years. Studies have shown that the high mortality rates in for-profit facilities contrast with those in the non-profits. In 2011, patients at the largest for-profit chain were found to have a 19% higher risk of death than patients at a non-profit; at the second largest dialysis firm the risk was 24% higher. No surprise, reduction of skilled nursing staffs has accompanied the rise and consolidation of for-profit dialysis providers in the U.S.
In its submissions to the state, Big Apple Dialysis anticipated making a 20% annual profit on the four HHC dialysis units. Big Apple Dialysis already has made millions of dollars in the operation of the 12 NYC-area chronic dialysis clinics. One clinic, Broadway Dialysis, was purchased from HHC in 2006. It continues to operate within HHC’s Elmhurst Hospital in Queens.
HHC: proven quality care
Clarette Fontanelle, a dialysis patient at Kings County for the past seven years, said, “I was so happy to hear this news. The dialysis nurses have been there for me. It makes a big difference.”
“Why interfere with such proven quality care?” said Harlem RN David Quarshie speaking of the four HHC units on the block in his testimony. That question has resonated throughout.