Physician-Dialysis Clinic Joint Ventures Need Transparency

Pam Harrison

October 08, 2018

Nephrologists who have entered into a joint venture with dialysis services must be more transparent, experts argue in a perspective article published online October 4 in the New England Journal of Medicine.

Without disclosure of financial interests, patients can't know if the procedure they are about to receive is their best option for care or if they are being referred to the facility that best fits their needs, write Jeffrey Berns, MD, professor of medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, and colleagues.

They point out that one of the least discussed aspects of the dialysis landscape in the United States is how often nephrologists are involved in a joint venture between dialysis companies and themselves.

In such an arrangement, the dialysis company usually owns a majority share of the business, and nephrologists either see patients at the facility or serve as its medical director. "Joint ventures allow the participating partners to share in the management, profits, and losses of an outpatient, maintenance dialysis facility," the authors write.

Although it can be argued that these joint ventures align nephrologists in a favorable way with the facility and improve patient outcomes and satisfaction, "[d]ialysis facility joint-venture arrangements are, within limits, exempt from prohibitions against physician self-referrals," the authors write. Yet there may be considerable self-interest inherent in those self-referrals, they suggest.

Despite the authors' best efforts, Berns and colleagues say they were unable to find any information regarding the number of dialysis facilities in which joint ownership played a role, or even which facilities had joint-venture owners or partners. "This lack of transparency not only poses a major barrier for evidence-based health care policy but also deprives patients of critical information: they cannot find out whether the nephrologist referring them to a particular dialysis facility has a financial incentive to do so," the authors state.

Vivekanand Jha, MD, executive director of the George Institute for Global Health in New Delhi, India, and professor of nephrology at the University of Oxford in the United Kingdom, couldn't agree more with the authors.

In an interview with Medscape Medical News, he said the lack of disclosure on a nephrologist's part prevents patients from making a clear, informed decision about the dialysis they are about to receive or about the quality of that dialysis, which can vary significantly between dialysis facilities.

"There is nothing wrong with nephrologists owning a joint venture [with a dialysis facility], but what is appropriate is for them to declare this to their patients, because there is a possibility that physicians might preferentially refer patients to those facilities," Jha said.

Preferential referral to a facility in which a nephrologist has a financial interest is problematic for a number of reasons, he continued. It may simply be that patients are being referred to a facility that is less convenient for them. Or it could be that the quality of the dialysis service to which they are being referred may be less than optimal. Patients can't properly weigh their options if nephrologists don't provide full disclosure about their financial interests in the referred facility. Importantly, too, "hemodialysis is a big business," Jha noted.

"But there are other types of dialysis, like home dialysis and peritoneal dialysis, that patients might prefer, and it is possible that nephrologists who have a preferential interest in a hemodialysis facility might not offer other choices to patients because they are trying to maximize their own profits in their own center," Jha said. Furthermore, patients vary greatly in the severity of their kidney disease and the presence of comorbidities.

Even if they do it unconsciously, nephrologists with a financial interest in a dialysis facility may be prone to "cherry pick" patients they send to their own facility, referring patients with less severe kidney disease and with fewer comorbidities in order to make sure that their facility's quality performance metrics are as high as possible, Jha added. "Nephrologists should be giving patients a menu of choices about which dialysis centers they potentially could go to and then let them know which units they have a personal interest in," Jha emphasized.

"Then at least patients can have a frank discussion about the advantages that one center might have over another," he said.

Berns and colleagues also point out that no information is available regarding which physicians or group practices have a financial stake in any of the end-stage renal disease seamless care organizations (ESCOs). "Thus, as with joint ventures, patients are unknowingly exposed to the risk that their care might be influenced by their physician's financial conflicts due to ESCO participation," the authors write.

To rectify the situation, Berns and colleagues suggest that nephrology specialty societies should develop guidelines on how nephrologists can appropriately disclose their financial interests in joint-venture arrangements or participation in an ESCO.

"We make no allegations regarding quality of care or illegal or unethical practices by nephrologists or dialysis companies as a result of joint-venture partnerships," the authors write. "Rather, we are advocating for far greater transparency and public availability of information about nephrologist participation in these business arrangements," they add.

"Only with such transparency can patients and their families make fully informed choices about their options," the authors conclude.

In 2015, the Centers for Medicare & Medicaid Services spent approximately $34 billion on patients with end-stage renal disease.

The two biggest dialysis companies in the United States, DaVita and Fresenius Medical Care, have each reported a net income of approximately $1 billion a year.

The authors have disclosed no relevant financial relationships. Dr Jha reports receiving grants from Baxter Healthcare and GlaxoSmithKline and personal fees from NephroPlus a dialysis provider.

N Engl J Med. Published online October 4, 2018. Abstract


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