29 November 1999

Pay and die?

by Kate Melville

In an interesting reversal to the tide of economic rationalism, new research from the Johns Hopkins School of Public Health indicates that kidney dialysis patients in for profit institutions had lower survival rates than those treated in not-for profit establishments.

The study published in the November issue of The New England Journal of Medicine, will surely generate further debate about the potential conflicts between for profit medicine and patient needs. "Our results raise serious concern that provider decision-making may differ within for-profit and not-for-profit organizations, and that the care of patients with end-stage renal disease may be compromised in for-profit dialysis centers, particularly in localities where not-for-profit facilities are absent," said Doctor Neil Powe, professor, Epidemiology and Health Policy and Management at Johns Hopkins.

Perhaps for profit hospitals should be remunerated based on clinical outcomes rather than for reducing costs and increasing patient turnaround? This may sound impossible but this report raises serious questions that impact much more widely than just for dialysis patients. To be fair in the US Medicare only pays dialysis centers a fixed fee per treatment and this amount has not increased since 26 years (since 1973). So the pressure to cut costs to try and maintain profitability is obviously a major factor, but few businesses could function without a price increase in the last quarter century.

In the John Hopkins study scientists studied a sample of 3,569 patients with new-onset end-stage renal disease (ESRD). Information about the patients and where they had been treated were obtained and then statistically adjusted to include the impact of 14 key clinical factors related to ESRD.

The patients in the study sample were treated at 950 different providers. These facilities were categorized either as for-profit (For-Profit); not-for-profit (Not-For-Profit); or hospital-based.

Information obtained by the research team found mortality rates were 20 percent higher in for-profit facilities. Patients at these for-profit centers were also 26 percent less likely to be put on the waiting list for a kidney transplant!

According to Dr. Powe, "Given that approximately 140,000 patients were dialyzed in for-profit centers in 1997, the observed increase in the absolute mortality rate among patients in freestanding, for-profit centers suggests that a considerable number of ESRD deaths may be associated with for-profit treatment. In addition, we observed that the association between for-profits and poor outcomes was diminished in counties where for-profits operated in proximity to not-for-profit dialysis centers."

In their work the John Hopkins researchers also used information from previous similar studies that showed for-profit facilities were more likely to provide lower doses of dialysis (as well as reusing them), practices associated with lower costs but lower rates of patient survival. A key issue in this disastrous equation seems to be insufficient staffing with workers having less time to assess and coordinate patient treatment. Unfortunately there is also some speculation that some facilities may be deliberately failing to refer patients for transplant in order to maintain patient numbers and therefore income.