Prop. 23 Asks: Should Dialysis Clinics Always Have A Physician On Site? (Transcript)

Dialysis is a health procedure that people with kidney failure need to survive. The process cleans toxins from the blood. (Mailson Pignata/iStock )

The Bay Curious team is breaking down each statewide proposition on the California ballot this year. If you haven't listened to our episodes on Propositions 14 to 22, check out the Prop Fest Page for more.

Today, we take on Proposition 23, which would require dialysis clinics to have a physician on site while patients are receiving care.


Olivia Allen-Price
[00:00:00] Hello. Hello. You're tuned in to Bay Curious Prop Fest, a twelve part series that explores the 12 propositions on the California ballot. I'm Olivia Allen-Price.

Olivia Allen-Price [00:00:11] Today we're on to Proposition 23, which would establish a new requirement for dialysis clinics. On your ballot it will read in part like this:


Voice 1 [00:00:22] Prop 23 requires at least one licensed physician onsite during treatment at outpatient kidney dialysis clinics.

Olivia Allen-Price [00:00:30] This one sounds simple on the surface, but has a lot going on when you take a closer look. We'll go through the ins and outs today on Proposition 23, the dialysis prop.

Olivia Allen-Price [00:00:43] KQED health correspondent April Dembosky has been following Prop 23. Hey, April.

April Dembosky [00:00:47] Hey, Olivia.

Olivia Allen-Price [00:00:48] Let's start off with just the top line here. What are we voting on in Prop 23?

April Dembosky [00:00:52] Proposition 23 is aimed at improving care at dialysis clinics in California. There are a few different parts to it, but the main thing is that it would require clinics to have a physician onsite during all hours patients are receiving treatment.

Olivia Allen-Price [00:01:07] One of my first thoughts when I saw this on the ballot was, didn't we already vote on this? Like I remember a ballot initiative from just a couple of years ago about dialysis.

April Dembosky [00:01:16] Yeah, a lot of people are having deja vu on this one. Two years ago, there was another dialysis measure on the ballot and the same groups that were for and against it last time are the same groups duking it out this time. So, at the core of both ballot measures is a labor dispute on the yes side is SEIU [Service Employees International Union] a union that represents health care workers at various hospitals like nurses and maintenance staff. And they've been trying to organize workers at dialysis clinics for about four or five years now. But the companies put up a fierce resistance to those efforts. That's DeVita and Fresenius [Medical Care], the two big dialysis companies in California, they are not interested in seeing their workforce unionized.

April Dembosky [00:01:56] So in 2018, SEIU put a measure on the ballot to try to get leverage with the dialysis companies. And this is actually a typical MO of the union. In the past, they've put measures on the ballot that sound appealing to voters but that they know will irk the hospital they're fighting with. Then if they get what they want from the hospital, they withdraw the measure. Now, with Prop 23, the companies say that the union is at it again and the union says they've given up trying to unionize dialysis workers, but they learned a lot about clinics along the way and the way that patients are cared for. And they say they're doing this for the patients. This is Steve Trossman, a spokesman for the union.

Steve Trossman
[00:02:35] This initiative is about improving conditions for patients, improving safety for patients and making the dialysis clinic spend some of the billions of dollars they make every year to improve their clinics.

Olivia Allen-Price [00:02:50] So is Prop 23 the exact same measure that we voted on in 2018?

April Dembosky
[00:02:54] No, it's different. Two years ago, the measure was about trying to limit the revenues that dialysis companies could take in to try to direct more money to workers and patient care. And the union was trying to hit them in the wallet. But it was a really confusing measure and voters voted it down. So the union went back to the drawing board pretty much right away to come up with a new measure, one that they hoped would be easier for voters to understand and perhaps more appealing. And they decided on this: Let's require dialysis companies to have doctors onsite full time for as long as patients are receiving treatment. Now, a lot of dialysis centers are open from 5:00 in the morning to 8:00 p.m. at night, so most are going to need two or three doctors to keep them fully staffed. And the state Legislative Analyst's Office says that's several hundred thousand dollars a year for each clinic. So, it's still a way for the union to hit the clinics in the wallet, but this time, maybe a bit more appealing to voters.

Olivia Allen-Price
[00:03:52] Now, before we get into the details of the measure, can you explain a bit about what dialysis is first and who gets it?

April Dembosky [00:03:59] Dialysis is for people with kidney failure. It's a procedure that cleans toxins from the blood. Most patients go three times a week for three to four hours each time. And you're exhausted afterwards. So it's a big disruption to life. A lot of people have to quit their jobs. Kidney failure can result from a variety of health conditions, but most often it's caused by diabetes or high blood pressure. And because people of color are more likely to experience these health conditions, they are more likely to be on dialysis. 57% of dialysis patients in California are either African American or Latino.

Olivia Allen-Price [00:04:37] Now, when I first read this measure, I thought, yeah, having doctors around to help with patients sounds like a great idea. I guess, is this a good idea?

April Dembosky [00:04:46] So, healthcare is complicated and it's hard to know if this would really help patients or if it might have unintended consequences. So patients already have their own doctors. They come see them in the clinics once a month or once a week to check on their dialysis, prescription medications, to monitor their labs. And researchers have studied whether the frequency of doctor's visits makes a difference in patients' health. Back in 2004, Medicare, the government health program that pays for most dialysis treatment, created a new incentive to encourage doctors to visit their dialysis patients more often. So instead of one or two times a month, it pushed them to visit four or more times per month. Well, after more than 10 years of doing this, it turns out seeing your doctor more often has no impact on health outcomes. In fact, patients who were seen less often by their doctor actually had better survival rates. So the government was paying doctors more money for more services with no conclusive benefits to show for it.

April Dembosky [00:05:51] Then there's a question of emergencies. Emergencies do come up. Patients and employees have told me that they've seen patients faint during treatment, or code, which means their heart stops. If someone's heart stops while they're in the clinic, nurses or technicians will do CPR. Maybe use a defibrillator and they will call 911 to have paramedics take them to the hospital. I spoke with Magellan Handford. He's been a dialysis nurse for almost 20 years and he's in favor of Prop 23. He says having a doctor on site would help with these kinds of emergencies.

Magellan Handford [00:06:23] Before we used to have – in our crash cart – we used to have medications like epinephrine and bicarb and different things to assist in a code. And we don't have those anymore. They took all of those off our crash carts because there's no doctor there to give instructions.

April Dembosky [00:06:41] But the people on the no side say that having a doctor there won't change any of the protocols and won't make any difference whether the patient survives or not. They would do the same CPR the nurses do, and they would still call an ambulance to take them to the ER. And there are some studies out there looking at ways to prevent this sudden cardiac death from happening, but they focus on medications patients take regularly or having patients use a wearable defibrillator to monitor their heart activity. But I haven't found any studies that suggest having a doctor at a clinic full time will impact sudden cardiac death among dialysis patients.

Olivia Allen-Price [00:07:17] Could having doctors around help with other aspects of dialysis patient health?

April Dembosky [00:07:21] The other big concern at dialysis clinics is infections. You're using catheters and needles to access the bloodstream. And dialysis patients have weakened immune systems that make it harder to fight infection. But all the best practices around how to prevent infections have to do with sanitation, cleaning the dialysis station, wearing gloves, washing your hands, and other antiseptic protocols. And doctor time doesn't really seem to affect this. Giving nurses more time to do these things could improve outcomes. But this measure doesn't mention anything like this. It would require clinics to report infection data to the state, but they already report the same data to the federal government.

Olivia Allen-Price [00:08:03] Is there possibly a downside to having doctors on site full time?

April Dembosky [00:08:06] So, just to be clear, clinics do have doctors affiliated with them, they're just not full time. Federal regulations require them to have medical directors and they're required to be kidney specialists. Prop 23 doesn't specify that the doctor on site has to be a kidney specialist. And there's a question about whether there's even enough kidney specialists in the state to go around. Dialysis patients will tell you that they've had encounters with other doctors at the hospital who are not specialists, who don't really know how to treat them or they make mistakes. And so this actually kind of scares them a bit, that this could be harmful.

Olivia Allen-Price [00:08:42] Yeah, some of the ads that I've seen are really scary and paint this as an issue of life or death. Let's listen to one from the no on Prop 23 campaign.

No on Prop 23 advertisement [00:08:52] One special interest group, again, is putting my life at risk. And Prop 23 could shut down my clinic. I'm not going to die from dialysis. I'm going to die without it. Prop 23 is dangerous. Please vote no.

Olivia Allen-Price [00:09:09] So, April, let's talk about this. Is it true that clinics will close if this passes because they just become too expensive to operate?

April Dembosky [00:09:17] So this is the same MO the dialysis companies used last time, threatening to shut down clinics. Two years ago they spent 111 million dollars on ads like this one to defeat the previous measure, and they're approaching similar spending on this one. And while it's possible that some clinics could close, it would likely not be an extraordinary number. And here's why: 3/4 of dialysis clinics in California are owned by two companies, DaVita and Fresenius. They're both for profit companies, and last year, they both did very well. Both made more than a billion in profits, and DaVita had a 16% operating margin last year. And for Fresenius it was 13%. And for health care, that is very good. But even beyond the question of whether these companies could even absorb these costs, there are ways that they could pass them on. So, they could go to insurance companies and say, hey, California passed this law, it's now going to cost us X percent more to deliver dialysis treatment, and because we control most of the market, we're going to need you to shoulder some of that costs. Otherwise, we're not going to deliver the care.

Olivia Allen-Price [00:10:23] OK, so maybe this won't bankrupt the dialysis clinics, but it's not really clear how much having doctors around will really help the situation either. So, I guess, is this worth some money?

April Dembosky [00:10:34] So, there's a big picture consideration here. You know, more is not always better in health care. The U.S. spends almost 18% of GDP on health care, and that's more than any other developed country. But our outcomes are worse. And so, you know, spending more money on health care does not always result in patients doing better. And health care policy in general is trying to take this into account. California and the country have actually been moving in the opposite direction of having doctors do everything. Doctor's time is really expensive and there's a recognition that there are a lot of health care duties that just don't require the expertise of a doctor.

April Dembosky [00:11:12] So, in fact, the governor, California governor, just signed a couple new laws that give nurse practitioners and nurse midwives more autonomy to practice without a doctor's supervision. Health advocates believe that these kinds of measures will actually make healthcare more affordable and more widely available, like in rural areas where it's hard to attract enough doctors. So, putting this measure on the ballot, voters are being given a big responsibility here, they're being asked to make health policy. We have to decide how much better things might be having doctors on site, and if it's worth the cost. And a lot of patients out there are really uncomfortable with voters being the one doing this balancing act, they think lawmakers should be the one to weigh all these factors and make decisions about how clinics should be regulated. I talked to one patient, DeWayne Cox, and he does not like Prop 23 at all because of this:

DeWayne Cox [00:12:05] When I see these propositions that are put before the voters, who have no idea what we go through and what's necessary to keep us alive, it makes me angry. Because they're, they're playing politics, for whatever their reasons are, but they're putting patients like me in the middle of it.

Olivia Allen-Price [00:12:32] April, what's the spending ban on this ballot measure so far?

April Dembosky [00:12:34] It's been pretty lopsided. The dialysis companies have been putting in about 93 million dollars so far to try to defeat the measure. And the unions have put in just a little bit over 6 million to try to get voters to pass it.

Olivia Allen-Price [00:12:51] All right, KQED health correspondent April Dembosky, thanks.

April Dembosky [00:12:55] You're welcome.

Olivia Allen-Price [00:12:58] In a nutshell, a vote yes on Prop 23 says you want dialysis clinics to follow these new requirements. A no vote says you want to keep things the way they are now.

Olivia Allen-Price [00:13:12] Join us tomorrow for our episode on Prop 24 about consumer privacy. It's one of the more complicated measures on the ballot this year. Bay Curious Prop Fest is made by Katrina Schwartz, Rob Speight, Katie McMurran, and me, Olivia Allen-Price. Our show is produced in San Francisco at Member Supported KQED. Thanks for listening.