Despite the move towards prevention and home care, dialysis providers are going to continue seeing growth.
Though new transparency rules worry dialysis providers, DaVita HealthCare Partners says the demand for the kidney-care services is driving its business forward.
Earlier this year, the Centers for Medicare & Medicaid Services for the first time published five star quality ratings on dialysis providers, sparking concern from major clinic operator DaVita HealthCare Partners and its peers about the methodology going into the process. For DaVita, though, the scores were good, with the company making up more than 50 percent of the 5-star facilities.
"We have enough metrics and proxies that while it might not be perfect, it is useful in making your decision," aid Javier Rodriguez, CEO of DaVita Kidney Care, the large division of DaVita.
The Dialysis Facility Compare star ratings measure nine aspects of the treatment, including standard mortality, hospitalizations, transfusions and the percentage of patients using catheters or fistulas, a surgical connection of arteries and veins that can help avoid the infections associated with catheters.
Over the last decade, when DaVita was growing nationally, "we thought about getting patients the best outcome out of the hospital, and one of them is the fistula," Rodriguez said.
"10 years ago, we said to a panel of 10 nephrologists, 'What would be the biggest gift we could give to patients?' The answer was reduce the catheters," Rodriguez said, even though "conventional wisdom always said you can't reduce it."
DaVita ended up bringing down the percentage of patients with catheters from more than 25 percent to around 13 percent, while increasing the use of a fistula to more than 65 percent, in line with recommendation of CMS and the National Kidney Foundation.
"The data helped us start conversations with medical leaders about improving," Rodriguez said.
Rodriguez joined DaVita in 1998, just as CEO Kent Thiry was trying to start a turnaround of the near-bankrupt Total Renal Care. The new DaVita, headquartered in Denver, went on to become one of the two largest dialysis providers in the country, with profits consistent enough for Warren Buffett, whose Berkshire Hathaway owns 17 percent of the company.
But DaVita has its problems, too. It's facing as much as $495 million in liability for a number of whistleblower lawsuits alleging referral schemes and physician contracting violations, but the company said it is investing $25 million in legal compliance. The company is also trying to keep growing, though, through joint ventures. After a $4 billion acquisition in 2012, DaVita HealthCare Partners is largely comprised of two different businesses, one a large dialysis provider and the other an operator of medical groups in value-based networks.
HealthCare Partners has management and operation ventures helping run medical groups and physician networks in California, Colorado Nevada, Florida, and Pennsylvania. One joint venture is with Philadelphia insurer Independence Blue Cross, a primary care-focused narrow network branded as Tandigm Health.
HealthCare Partners uses a "team-based approach," with a "team of primary care providers, specialists, case managers and other professionals who work together to manage all aspects of patient's' care and overall health," wrote Tracy Wakefield, MD, a HealthCare Partners physician in Nevada. "This includes a strong focus on prevention and assisting patients with maximizing their health insurance benefits."
Rodriguez, head of DaVita's dialysis company, said those efforts on prevention won't diminish the incidence of end-stage renal disease and the need for dialysis anytime soon.
"Maybe in 20 years, but if you look at the ingrained habits of America, diet, exercise and smoking, those habits are not going to change in 5 year time horizon," he said. "The ESRD trend will take a while to reverse. People have been trying for years."
Kidney care delivery, including dialysis and the potential rise of home-based peritoneal dialysis, "is going to change," Rodriguez said. "We will be accountable for a lot more of their care."
Even though it is growing, the rise of home-based dialysis will likely not overtake the facility-based hemodialysis, Rodriguez argued. Hemodialysis requires patients who spend 12 or more hours a week in a clinic but can use the fistula and avoid infections and clots. Peritoneal dialysis lets patients use a catheter-based system at home or as they travel.
"For a long time, conventional wisdom would say, wouldn't people want to get it at home? The modality hasn't grown."
Especially for some patients, he argued, dialysis can be a beneficial ritual of coming to the clinic, talking with staff or listening to music. It's a similar unnoticed benefit with community pharmacies. For some seniors, a trip to CVS or RiteAid can be one of few trips away from home. "A lot of patients need help, and in a lot of our centers, they have a very social and home feel to them," Rodriguez said.