How safe are dialysis centers? California bill would require more oversight

Updates: Dialysis patients and supporters of Senate Bill 349, the Dialysis Patient Safety Act, are scheduled to rally at 11 a.m. Thursday, Aug. 24 at San Joaquin Valley Dialysis Center, 3636 N. First St. On Aug. 9, a California ballot initiative supported by Service Employees International Union-United Healthcare Workers West, was filed that would require annual inspections of dialysis clinics in California, safer staffing levels and more recovery time for patients at dialysis clinics and would limit the amount dialysis patient may be charged. The union says that in October it expects it will begin collecting the 365,880 signatures to quality the initiative for the November 2018 ballot.

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Clinics that provide dialysis for people with diabetes and others with end-stage kidney disease in the central San Joaquin Valley and statewide could be required to have more staffing and be inspected annually if a bill in the California Legislature becomes law.

The legislation, which would also require a set amount of time for cleaning equipment between patients, moved out of the Senate Appropriations Committee on Thursday. It has to be approved on the floor of the state Senate by next Friday to move to the Assembly.

Senate Bill 349 has loyal backers and detractors.

Those in support of the Dialysis Patient Safety Act say it is necessary to assure safety for dialysis patients who are susceptible to infection. Opponents say California clinics are among the highest rated in the country, and the proposed rules could result in fewer patients being treated and could possibly cause centers to close in rural communities, such as those in small Valley cities.

The legislation could affect more than 60,000 Californians who have end-stage kidney disease and who are need of dialysis to filter impurities from their blood. While it’s not known how many people in the Valley are receiving dialysis on any given day, the region has high rates of diabetes, which can lead to kidney disease. And about two dozen dialysis clinics in the Valley stay very busy.

Irene Botello, 35, of Fresno, is closely following the legislation in Sacramento. She has had diabetes since childhood and for the past seven months has had dialysis three times a week. Last month, she participated in a rally at the Capitol in support of the legislation.

Botello said the staff are hurried at the clinic she goes to in central Fresno. “Things happen, like our blood pressure drops or our blood pressure goes up. Somebody has to get off (the dialysis machine) and somebody has to take them off … there’s not enough people to get us off on time or whatever we need.”

On one occasion, Botello said, she needed a technician to unhook her tubing and take her to her wheelchair so she could go to the restroom. But she had to wait too long for assistance and soiled herself.

“Everyone is doing their jobs, but there’s just not sufficient people,” she said.

During another of her dialysis treatments, Botello said, a patient died. Staff responded and gave him cardiopulmonary resuscitation, but it unnerved her. She’s afraid to recline in the dialysis chair for fear of falling asleep. “I don’t know if they’re going to be paying attention to me.”

Sen. Ricardo Lara, D-Bell Gardens, who introduced the California dialysis legislation, said patients in dialysis clinics should have the same protections as people have in hospitals. California adopted minimum nurse staffing ratios for hospitals several years ago. The state does not have a minimum staffing requirement for dialysis clinics.

“Dialysis patients are such a vulnerable group that is already going through very extraordinary circumstances,” Lara said. “We want to make sure they’re safe and have appropriate staffing levels to assure the quality of health care for Californians,” he said.

The legislation would increase state oversight. Currently, dialysis clinics are inspected on average every five to six years, while nursing homes in California must be inspected every year.

Lara’s bill has the backing of the Service Employees International Union-United Healthcare Workers West, which has said dialysis workers regularly report staffing levels so low that it threatens patient care. Dialysis workers have been organizing to join the union.

The debate over the California dialysis legislation comes at a time when clinics have faced negative publicity from an HBO “Last Week Tonight with John Oliver.” The critical segment has been viewed more than 4.2 million times on YouTube.

Opponents of the legislation have said it is unnecessary. California dialysis centers rank among the highest for quality by the federal Centers for Medicare & Medicaid Services, and there is no evidence that specific nurse-to-patient ratios would lead to greater safety for patients, they said. They also have concerns about a 45-minute transition time between patients.

Dr. Amy Gen, a Fresno nephrologist, sees patients at various dialysis centers in Fresno County. The proposed staffing requirements could result in fewer people being able to receive dialysis, she said. “Imagine if someone gets sick on the job and they have to leave and they can’t fill that spot right away. Those patients would have to stop dialysis and leave.”

The 45-minute turnaround time also could reduce access to dialysis, she said. Patients’ treatment could be delayed if they have to wait because another patient has had problems that extend dialysis.

A lot of working patients choose to be scheduled on the last shift at a clinic, which begins after 6 p.m., Gen said. But some clinics might have to drop the fourth shift, she said.

Dialysis corporations referred questions about the California legislation to a representative of DialysisPatients1st, a coalition of renal physicians, nurses and patient groups that is fighting the bill. The coalition contends the proposed regulations would increase the cost of providing dialysis care and that the extra cost could be passed on to Medi-Cal, the state-federal insurance for people with low incomes. Rural clinics in the Valley have large numbers of Medi-Cal patients, the coalition said.

The group also said that finding nurses for rural dialysis clinics to meet a mandated staffing ratio could be difficult and possibly force operators to close clinics.

Gen, who is medical director at the Ash Tree DaVita dialysis center in Fresno, said there are upwards of 14 clinics in Fresno County and all are needed. She remembers a decade ago when there were only three. Patients would wait three to four weeks in the hospital for a spot at a clinic to open, she said. “I hope that doesn’t come again. If we lose a couple of units or even a handful of shifts, that’s where we’re going to be.”

Lara’s staff said Medicare, not Medi-Cal, is the most common payer for dialysis services. And Lara disputes the assertion that the legislation would cause clinics to close. Rural dialysis clinics typically have one nurse present at a time now. It’s a requirement for a state license that at least one nurse be present, he said. The clinics have always faced the challenge of finding registered nurses and the legislation would not change that, he said.

Dialysis clinics have the money for more staffing, Lara said. The majority of the dialysis clinics in California – and in the Valley – are operated by two dialysis corporations, DaVita and Fresenius Medical Care. Lara said: “Look at their financial statements. They are very, very profitable operations in California and nationally.” The union has said they make $2.9 billion a year in profits.

This story was originally published May 28, 2017 at 8:00 AM with the headline "How safe are dialysis centers? California bill would require more oversight."