July 27, 2017

Nephrology News & Issues: California staff ratio bill would hurt clinics in urban and low income areas

California staff ratio bill would hurt clinics in urban and low income areas July 25, 2017 Omaran Abdeen, MD and Parag Shah, MD We have been practicing as kidney doctors for 15 years in Sun Valley, California, a city on the outskirts of Los Angeles. We opened Laurel Canyon Dialysis, a dialysis facility in the heart of Sun Valley, about two years ago and currently serve around 200 patients. Residents from here and the surrounding areas are predominately Latino and have a lower median income than the rest of Los Angeles County. It’s also an area that has seen a significant growth in the number of residents with kidney failure and consequently an increased demand for dialysis treatments. Statewide, the number of people who need dialysis is growing at a rate of about 5% per year, one of the highest rates in the nation. As nephrologists and facility owners, we have some concerns about State Senate Bill 349.The bill is making its way through the California legislature and would mandate staff-to-patient ratios for nurses, patient care technicians, social workers, and dietitians in California dialysis clinics. In our view, SB 349 will reduce patients’ access to dialysis, particularly in low-income areas of the state, and disproportionately affect the elderly and minorities. This bill, which is supported by the labor union United Healthcare Workers, will hit clinics who treat patients in underserved, low-income areas the hardest. Some of our patients are visually impaired, others live in nursing homes, and many are transported to our clinic three times a week for dialysis, making this an immensely burdensome illness. Thirty percent of our patients are on Medi-Cal as their sole source of health care coverage. Medi-Cal covers health care costs for low-income Californians and provides reimbursements for dialysis that are significantly lower than the cost of care. We have done the math and to keep our doors open we likely won’t be able to afford to hire the additional staff needed to meet the SB 349 mandates. Instead, we plan to close our 4th shift, the last afternoon/evening shift. This will displace about 50 of our patients, many of whom need to come to dialysis after work so they can support their families. They will have to seek care elsewhere, but will probably have a hard time finding clinics with available appointment slots. A solution in search of a problem While mandating additional staff may sound like a reasonable idea, the bill ignores the fact that California’s dialysis clinics—as currently staffed—provide some of the best care in the country as measured by independent government data. Data from the Centers for Medicare & Medicaid Services, which tracks performance at dialysis clinics, shows that California is already doing better than clinics in other states in quality of care and patient satisfaction. On average, California has more 4- and 5-star clinics in Medicare’s Star Rating System than the rest of the nation. We also have higher patient satisfaction scores. This is an important point because one of the unintended but almost certain consequences of SB 349 is that clinics like ours won’t be able to afford the additional salary and benefit costs of hiring more staff to treat the same number of patients. A survey of dialysis clinics by the California Dialysis Council found that nearly two-thirds of their members said they would consider cutting their late afternoon and evening shifts if SB 349 passes. One hundred and twenty-one clinics said they would consider closing. Bottom line: More than 15,000 out of about 64,000 dialysis patients in California will be displaced. What happens then? It’s likely that patients will end up dialyzing in hospitals which is much more expensive for the state and places their health at significant risk. So then why is this bill being proposed? Obviously, it’s not about patient care. Clearly patients will be on the losing end if this bill passes. This is about union politics and nothing more. As doctors, we strongly support efforts to improve patient care. But SB 349 is a solution in search of a problem that will hurt patients on dialysis by limiting access to care they desperately need. It disproportionately affects the elderly and minorities. We believe it is important to put our patient’s lives above politics.