Government turns attention to quality of kidney dialysis Efforts recognize severe problems affecting patient care


After more than a quarter-century with little attention from the government, the quality of kidney dialysis in the United States is receiving scrutiny from the Clinton administration and Congress.

The administration is preparing proposals to establish quality requirements for dialysis, a life-saving treatment for patients whose kidneys have failed.

The proposals, which could be ready by March, would define such things as the results that must be achieved in certain blood tests indicating the quality of dialysis.

At the same time, the government is exploring ways to strengthen enforcement of standards at dialysis centers through increased inspections, administration officials said.

The administration is also reviewing the way the government pays for dialysis in hopes of finding an alternative that would offer more financial incentives for providing quality care, administration officials said.

On Capitol Hill, Republicans and Democrats are considering holding hearings this year on the quality of dialysis, senior congressional aides said.

Rep. Pete Stark, a California Democrat, is preparing legislation that, in addition to creating quality standards, would require that patients be told how their clinic compared with others in meeting those requirements.

The efforts resulted largely from a growing recognition that there are severe problems affecting patient care throughout the business. The mortality rate for dialysis patients in this country hovers around 23 percent, more than twice that of Japan and some European nations.

But some say that comparison is unfair because U.S. dialysis patients are older and sicker than patients overseas. But even after adjusting the numbers for age, severity of illness and other factors, American patients are still significantly more likely to die in a given year than similar patients in other countries, according to many kidney specialists and studies in prominent medical journals.

Indeed, virtually every large dialysis provider and kidney-patient organization has sponsored medical studies and symposiums to explore the poor performance compared with other countries. But few changes have been made in the federal dialysis program.

Problems in the dialysis business were detailed in a series of articles by the New York Times last month. The articles, which focused on the dialysis industry and its leading company,

National Medical Care Inc., also described a government compensation system that rewards dialysis companies for cutting costs, even at the expense of patient care, and "accelerated our efforts to modernize and largely change both our quality standards and our enforcement procedures for dialysis facilities," said Bruce Vladeck, administrator of the Federal Health Care Financing Administration.

The agency runs the Medicare program that pays much of the bill for the nearly 200,000 Americans on kidney dialysis. Some federal health officials say one answer to federal compensation questions might lie in a pilot program being developed by Medicare administrators.

Under this program, known as capitation, the government would contract with a dialysis provider to serve all the medical needs of a kidney patient for a prearranged price, rather than just to provide the dialysis itself.

That way, the dialysis provider would have a financial incentive to keep the patient healthy.

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