Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Involuntary discharge from dialysis: A health care practice like no other

Robert Allan Bear, MD
Physician
January 9, 2017
3K Shares
Share
Tweet
Share

Chronic kidney failure is a serious disease. When progression to end-stage renal disease (ESRD) occurs, dialysis is required to sustain life.

It is shocking, then, that in the United States, it is estimated that over 1,000 patients annually are involuntarily discharged from their dialysis clinics. Further, they are often “blackballed” from other local clinics. The consequences for such patients, predominately African-American, are dire. A patient may be unable to find a local clinic that will accept them, thereby being required to travel great distances to receive their thrice-weekly dialysis.

Some end up visiting hospital emergency departments, where they will receive only intermittent dialysis when in extremis; others die. This health care practice — the involuntary removal of substantial numbers of patients each year from the treatment that sustains their lives —  is without parallel.

Provider organizations defend their actions thusly:

The patient has no insurance. This is a rare occurrence in a system in which most dialysis costs are paid by Medicare. And, in a just health care system, if a patient cannot pay, should this ever be a reason to terminate care?

The patient does not follow medical advice. In a health care era focused on patient-centered care, patient engagement, and joint decision-making, could this ever be a valid reason?

The patient has a mental health disorder. Should the presence of one serious chronic disease ever deprive a patient of life-preserving care for another chronic disease?

The patient is violent and is a risk to other patients and staff. In reality, reported incidences of serious violence perpetrated by dialysis patients are rare; most ‘violence’ is verbal, precipitated by personality conflict based on cultural differences, low health literacy, and poor communication. These are addressable issues.

The patient is disruptive. When this reason is explored, it often turns out that the patient has expressed quality-of-care concerns; labeling the patient as disruptive and involuntarily discharging him/her, is a form of retaliation. Patients understand the ability of dialysis centers to do this, and many describe feeling intimidated, captive and vulnerable.

All of the above is well-documented in the public domain. Investigative journalists have published exposés. Patients have told their stories on- line. Legal opinions and summaries of legal actions have been published. Physician associations have lamented the practice of involuntary discharge and have published voluntary guidelines intended to limit it. Bloggers have raged. Yet the practice continues, as does the human suffering it engenders.

Involuntary discharge from dialysis — a life-sustaining treatment — is a uniquely American phenomenon. It is not reported with any frequency in other first-world countries. In Canada, as just one example, it would be impossible to involuntarily discharge a dialysis patient from a treatment center. Accordingly, this phenomenon offers key insights into the American health care system and into the professional behavior of some of its practitioners, insights that are important at a time the system may be further privatized.

Why uniquely American? Over 80 percent of dialysis care in the U.S., care that costs Medicare over $35 billion annually, is provided by two for-profit public companies. Creation of shareholder value is the driving force of these companies. In fact, the CEO of one of these companies has proclaimed that “the business of [my company] is not about patients.” So short-cuts in dialysis staff training and supervision may add to the bottom line, but may also contribute to the phenomenon of involuntary discharge. And embedded in the CMS remuneration system are financial incentives beneficial to these companies that may explain why they allow the practice to continue.

What can be done? A number of opportunities exist that, taken advantage of, would result in meaningful change.

The accountability framework within which providers of dialysis care in the US operate requires strengthening.  The Center for Medicare and Medicaid Services (CMS) funds a system of regional End-Stage Renal Disease (ESRD) Networks. Among the purposes of these organizations: Providing assistance to ESRD patients and providers; and, evaluating and resolving patient grievances. In the matter of involuntary discharge from dialysis, dialysis patient advocacy groups have compiled abundant documentation confirming that the ESRD Networks typically provide little meaningful patient support at a time of involuntary discharge. Meanwhile, CMS refuses to ensure that ESRD Networks are held accountable in meeting their prescribed responsibilities to patients. Curious.

The Affordable Care Act contains a Patients’ Bill of Rights. While helpful, it does not address all of the needs of dialysis patients. Each ESRD Network should ensure the existance of a functional Dialysis Patient Bill of Rights and Responsibilities.

The involuntary discharge of a patient is unlikely to occur in a dialysis clinic environment in which there is a commitment to elements of patient engagement such as patient education, improved communication between providers and patients, and shared decision-making. Scientific studies from Australia and Europe have demonstrated that it is possible to dramatically reduce workplace conflict by implementing educational programs for staff and patients. CMS is requiring each of its regional networks to develop patient engagement initiatives. This is encouraging, but will require time.

A complex network of relationships exists between CMS, the Regional ESRD Networks, provider organizations, and some not-for-profit kidney agencies. Stark examples of conflict-of-interest exist. Furthermore, within this network, patients are poorly represented, and, as a consequence, their interests by-passed. Dialysis industry relationships should be made more transparent, conflicts-of-interest eliminated and patient representation improved.

It is unlikely that most U.S. citizens are aware that each year, a significant number of patients — typically African-American, disadvantaged and vulnerable — are unilaterally discharged from the health centers that provide their life-preserving care. It is a strength of countries such as the U.S. that heightened public awareness of an issue often results in change. Howard Koh, from the U.S. Department of Health and Human Services, has emphasized this, saying: “Advocacy is the engine for change, and the beauty of it is that it can begin with just one person.” Exactly. Each of us has a role to play in addressing this important health care issue.

Robert Allan Bear is a nephrologist.

Image credit: Shutterstock.com

Prev

Do primary care physicians increase life expectancy?

January 9, 2017 Kevin 8
…
Next

The Cures Act comes with some big questions

January 9, 2017 Kevin 1
…

Tagged as: Nephrology

Post navigation

< Previous Post
Do primary care physicians increase life expectancy?
Next Post >
The Cures Act comes with some big questions

More by Robert Allan Bear, MD

  • The culture of my health care organization is broken. Is there hope?

    Robert Allan Bear, MD
  • To aspiring physician-writers: It’s time to write that book!

    Robert Allan Bear, MD
  • a desk with keyboard and ipad with the kevinmd logo

    The secret sauce of great health care organizations

    Robert Allan Bear, MD

Related Posts

  • How social media can help or hurt your health care career

    Health eCareers
  • Turn physicians into powerful health care influencers

    Kevin Pho, MD
  • Why health care replaced physician care

    Michael Weiss, MD
  • Health care is not a service commodity

    Peter Spence, MD, MBA
  • Why the health care industry must prioritize health equity

    George T. Mathew, MD, MBA
  • Improve mental health by improving how we finance health care

    Steven Siegel, MD, PhD

More in Physician

  • A tense family drama unfolds as a young daughter pursues unconventional career path

    Osmund Agbo, MD
  • Decoding the brain’s decision-making: insights for medical professions and strategies for success

    Harvey Castro, MD, MBA
  • Unmasking the truth: the shocking reality of the opioid epidemic and who’s really to blame

    Jay K. Joshi, MD
  • Discover your true north: Navigating life’s confusions and embracing your path to success

    Tyler Jorgensen, MD
  • Revealing America’s expansion: the dark truth of Native American suffering and unjustified abuses

    Anonymous
  • From journalism to medicine: Unveiling the untold stories of patients’ medical conditions

    Veronica Bonales, MD
  • Most Popular

  • Past Week

    • A physician’s typical day, as envisioned by a non-clinician health care MBA: a satire

      Jennifer Lycette, MD | Physician
    • Is chaos in health care leading us towards socialized medicine? How physician burnout is a catalyst.

      Howard Smith, MD | Physician
    • Revealing America’s expansion: the dark truth of Native American suffering and unjustified abuses

      Anonymous | Physician
    • The tragic story of Mr. G: a painful journey towards understanding suicide

      William Lynes, MD | Physician
    • The rising threat of lung cancer in Asian American female nonsmokers

      Alice S. Y. Lee, MD | Conditions
    • From Moscow Mule to the opioid crisis: Unveiling the tragic legacy and urgent solutions

      Osmund Agbo, MD | Meds
  • Past 6 Months

    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • An inspiring tribute to an exceptional radiologist who made a lasting impact

      Kim Downey, PT | Conditions
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Proactive risk management: a game-changer in preventing physician burnout

      Howard Smith, MD | Physician
  • Recent Posts

    • Physician employment contracts: the key to fighting burnout and improving working conditions [PODCAST]

      The Podcast by KevinMD | Podcast
    • A tense family drama unfolds as a young daughter pursues unconventional career path

      Osmund Agbo, MD | Physician
    • Decoding the brain’s decision-making: insights for medical professions and strategies for success

      Harvey Castro, MD, MBA | Physician
    • Unmasking the truth: the shocking reality of the opioid epidemic and who’s really to blame

      Jay K. Joshi, MD | Physician
    • Discover your true north: Navigating life’s confusions and embracing your path to success

      Tyler Jorgensen, MD | Physician
    • A revolution in patient empowerment: Working together to save our medical system [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 46 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Insomnia Symptoms Tied to Stroke a Decade Later
  • Studies Question Role of CDK4/6 Inhibitors in First-Line Advanced Breast Cancer
  • Full-On Reversal of Cardiac Amyloidosis Possible With Antibodies
  • Spell Check-Up: Do You Have the Skills to Pass This Spelling Test?
  • For Some, Sex Is Better Sleep Aid Than Pill, Small Survey Finds

Meeting Coverage

  • Studies Question Role of CDK4/6 Inhibitors in First-Line Advanced Breast Cancer
  • For Some, Sex Is Better Sleep Aid Than Pill, Small Survey Finds
  • Skipping Radiotherapy 'Seems Safe' for PMBCL Patients in Remission
  • Promising Gene Therapy for Overactive Bladder
  • Shotgun Sequencing of Small Intestine Reveals Species Tied to GI Symptom Severity
  • Most Popular

  • Past Week

    • A physician’s typical day, as envisioned by a non-clinician health care MBA: a satire

      Jennifer Lycette, MD | Physician
    • Is chaos in health care leading us towards socialized medicine? How physician burnout is a catalyst.

      Howard Smith, MD | Physician
    • Revealing America’s expansion: the dark truth of Native American suffering and unjustified abuses

      Anonymous | Physician
    • The tragic story of Mr. G: a painful journey towards understanding suicide

      William Lynes, MD | Physician
    • The rising threat of lung cancer in Asian American female nonsmokers

      Alice S. Y. Lee, MD | Conditions
    • From Moscow Mule to the opioid crisis: Unveiling the tragic legacy and urgent solutions

      Osmund Agbo, MD | Meds
  • Past 6 Months

    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • An inspiring tribute to an exceptional radiologist who made a lasting impact

      Kim Downey, PT | Conditions
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Proactive risk management: a game-changer in preventing physician burnout

      Howard Smith, MD | Physician
  • Recent Posts

    • Physician employment contracts: the key to fighting burnout and improving working conditions [PODCAST]

      The Podcast by KevinMD | Podcast
    • A tense family drama unfolds as a young daughter pursues unconventional career path

      Osmund Agbo, MD | Physician
    • Decoding the brain’s decision-making: insights for medical professions and strategies for success

      Harvey Castro, MD, MBA | Physician
    • Unmasking the truth: the shocking reality of the opioid epidemic and who’s really to blame

      Jay K. Joshi, MD | Physician
    • Discover your true north: Navigating life’s confusions and embracing your path to success

      Tyler Jorgensen, MD | Physician
    • A revolution in patient empowerment: Working together to save our medical system [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Involuntary discharge from dialysis: A health care practice like no other
46 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...