It seems really bad.
They reason at point A4 that "many dialysis clinics in California have been cited for failure to maintain proper standards of care." It seems like it would be easier to address those issues at those clinics than to take this astounding blanket approach.
They want to have a physician present while patients are in clinic to address any complications with treatments, but they do not have a firm grasp on what they are actually asking. Dialysis patients are monitored closely. Currently, dialysis patients are typically seen by a physician or NP/PA four times monthly for maximum visits and billing. The medical director or perhaps patient's attending is available by phone if there are any issues or concerns.
To have a physician on site will cost both the physician and the dialysis company. Davita/Fresenius may have their own staff in some areas, but much of the time, they have an agreement with local private practices to see patients in the clinics and perform director duties. If a physician has to be on site during all the treatment times, that physician cannot do anything else at the time. And this is not a small amount of time lost; if a clinic runs 3 shifts on different day schedules (MWF, TTS), the clinic is treating patients 12 hours a day, 6 days a week! They want a physician to be there for 72 hours weekly while doing little. We probably spend about 30 minutes per month directly on a patient's care with the regular visits. Nephrology does not get paid to do more beyond the 4 visits that can be billed or the medical directorship fees. Therefore, the dialysis clinic would have to compensate the physician for his time spent (wasted). Currently, it is against the rules to see one's own patients at a dialysis clinic so there is not a world where one could be present for dialysis and keep on doing other work. I also would not expect a physician to happily increase his regular outpatient work week to 70+ hours (including Saturdays!).
It's crazy. Dialysis patients are at risk of complications, but dialysis clinics are not hospitals or EDs or urgent care clinics. They have training to do dialysis on stable patients and to provide some emergent care that any typical clinic would provide. Think medications for anaphylaxis or code carts. If a patient is unwell, they are sent to the ED by family if okay or ambulance if not. I am not sure what they expect physicians to really do. There is a lot of concern in the bill about infection, but there are protocols to evaluate and address that. Sick? ED->hospitalization->antibiotics, etc. They can send off cultures if there is "suspicion" based on appearance but no overt findings for acute illness. What am is a doc supposed to do in clinic if he/she thinks someone has bacteremia? Does a physician need to be there for a code that happens once a year? Bleeding concerns? The dialysis staff have more training to manage that than I do. I think whatever could be gained by having physicians readily available will be lost by magnitudes for patients on PD/HHD, with CKD in clinic, with transplants who are losing their physicians to this black hole for time. There will be a physician shortage undoubtedly.
There is also some odd language regarding payment for dialysis that I do not really understand the purpose. They are concerned about patients' ability to pay for dialysis, but dialysis is covered by Medicare. They should know that. None of my patients are paying for treatment out of pocket. Medication can be a challenge, but that is a different issue and as far as I can tell not really addressed by this initiative. I have to think they are strong-arming the dialysis companies to eat the cost for illegal immigrants who are ESRD. That's not actually that bad if they paid the clinics for it. There is enough data to show patients do better, and it is cheaper to go ahead and treat them routinely rather than let them crash into the ED/hospital for urgent dialysis.
At the end of the day, it feels like they are trying to stick it to the dialysis companies who will lose money but so will physicians, and patients will lose access to their nephrologists as well.
ballotpedia.org
