Dialysis in Rural America
By Dorothy Nguyen
Most people rarely think about dialysis. But for those who rely on it, it can be nearly all they think about. This was the case for many during this past election when California voted on Proposition 23 — a proposition requiring a physician on-site at all times, mandated infection reporting, and prohibition of discrimination based on insurance [1].
Dialysis does the work of filtering blood when the kidneys are no longer sufficiently functional. Of the two types of dialysis—hemodialysis and peritoneal dialysis—hemodialysis is colloquially recognized as dialysis. Patients undergoing this treatment go to dialysis centers three times a week for hours at a time so that the dialyzer machine can clean wastes that have accumulated in their blood between consecutive visits. Without treatment,the build up of toxins in the bloodstream would result in death. Consequently, the lack of dialysis centers in rural areas is detrimental.
While an on-site physician at centers as proposed by Prop 23 would improve the response times and outcomes of emergencies, opponents worried that the extra expense would deter for-profit dialysis companies from maintaining less profitable centers in rural areas [2]. The nature of the dialysis industry heightens accessibility issues already present in other medical treatments, resulting in a tradeoff between quality and availability, particularly in rural areas.
Dialysis and Transplant Inaccessibility
The sparse population and geographical spread of rural areas make it difficult for its communities to get enough medical treatment. One in five Americans lives in a rural area, where there is higher mortality from end-stage renal disease (ESRD) and co-morbidities. This is further complicated by the lower availability of healthcare resources such as nephrologists and other dialysis center staff that would make the physician requirement of Prop 23 more unattainable for rural regions. 33% fewer primary care physicians are present to monitor co-morbidities, and patients need to travel 2.5 times further to dialysis centers than urban patients [3] (median 13.7 miles to urban centers compared to 33.3 miles to rural centers [4]). 23.5% of urban patients need to travel out of the county to a center, compared to 63.9% in small adjacent rural areas and 77.3% in remote rural areas [4].
There are also less home hemodialysis training, after-hours services, and rural counties with peritoneal dialysis available at centers despite being a convenient and more frequently used alternative to regular visits [4, 5]. Furthermore, long-term mortality is more common in rural peritoneal dialysis patients than their urban counterparts [6]. It is difficult enough to stay healthy without secure access to grocery stores, health professionals, medical facilities, and community resources that rural areas often struggle with. Patients not only need to compromise their time for travel and treatment, but also their family members or caretakers if a household has limited cars and transportation options.
Location-based disparities are exacerbated when race is taken into account, evident by the difficulties that Black patients face in relation to transplantation. Black patients spend 2.5 months longer waiting for transplants, and their bodies are more likely to reject a transplant within 5 years compared to white patients, whose bodies have higher rates of rejection after 6 months and 1 year [7]. Even being put on a transplant waiting list by a physician is more difficult for rural Black patients because of the scarcity of centers with transplant programs in the vicinity.
This is compounded by a race coefficient, which assumes that Black patients have higher muscle mass and makes the estimated glomerular filtration rate higher. As a result, Black and white patients of similar creatine (a substance in the blood that indicates kidney function) levels would have differently perceived kidney function such that white patients have low enough estimated glomerular filtration rate to be put on transplant lists while Black patients of similar state are cemented in subpar and delayed treatment. The race coefficient remained a part of GFR calculations even since a refined equation in 2009, but it is up for revision in 2021 [5]. What organizational factors are responsible for such disparate and profit-driven dialysis treatment?
The for-profit nature of the dialysis industry
There is a near-monopoly where 70% of dialysis centers in the US are run by Davita or Fresenius, and 80% of all dialysis patients rely on these centers [8]. New centers are acquired from smaller owners one by one in order to evade federal oversight of corporate mergers.
Without competition, Davita or Fresenius have not only a monopoly but also a negotiating power to increase insurance reimbursements and decrease prices from their suppliers to maximize profits. The average cost of dialysis covered by Medicare is $240 per session, compared to $1000 per session for private insurance [8]. Major companies maintain a bigger profit margin by donating to organizations like the American Kidney Fund to keep patients on private insurance longer. Less competition, however, can contribute to lower quality and reduced incentive to maintain less profitable sites that do not serve as many patients.
Prop 23 was not the first effort at dialysis regulation. Only 2 years prior in 2018, California voted on Proposition 8, also known as the Fair Pricing for Dialysis Act. This aimed to cap profits at 15% in hopes that dialysis centers spending more on equipment and training would lower infection and death rates [8]. The expectation was that companies would invest more money in patient care instead of cutting corners, even though no specific improvements were required.
More importantly, proponents hoped it would establish a sense of accountability for patient health from big dialysis providers. Assembly Bill 290 (AB 290) in 2019 required dialysis centers to charge reduced rates: either the same as Medicare or a differently determined rate for patients getting aid from the American Kidney Fund [8]. This made the American Kidney Fund unable to provide continued assistance to California patients. A similar bill was vetoed in 2018. Similar to Prop 23, these efforts failed to pass because citizens, governors, and federal courts were concerned about higher operation costs shutting down centers and resources for rural and low-income communities. They set a pattern of yielding to dialysis companies.
Potential Solutions
Physically inaccessible hemodialysis sites for rural communities have been met with home or peritoneal dialysis. A study found that 6 home hemodialysis sessions a week resulted in a reduction of depressive symptoms, the percentage of patients expressing depressive symptoms after 12 months, and recovery time from post-dialysis fatigue [9]. Home hemodialysis users had a lower chance of hospitalization for cardiovascular problems like cerebrovascular disease, heart failure, and hypertension compared to peritoneal dialysis patients [10]. A Wisconsin study found that centers with peritoneal dialysis resources were nearly nonexistent in rural areas, but monthly and gradually less frequent visits to maintain peritoneal dialysis treatment is feasible with the incorporation of telemedicine [11]. Alleviating comorbidities and increasing easily available care could significantly improve the outcomes and quality of life of those far away from dialysis centers.
However, hurdles to regular and quality care will not go away easily. Many rural areas lack the broadband infrastructure to accommodate telemedicine, and remote check-ins are not as safe as accessible in-person centers. The question of whether or not to regulate dialysis companies continues to be a balancing act between quality of care and access for those who need it. Should life and death decisions be made by under qualified voters? UCLA law and political science professor Mark Peterson states that dialysis is “a highly technical issue in a realm that gets into…the nature of care. That is not something that any of us in the general public are trained in” [12]. He suggests that these issues could be better suited for more nuanced discussion in the Legislature [12]. The public voting record has already proven to prioritize the accessibility of life-saving dialysis facilities in rural communities, but health and legislative professionals need to address the structural roots of these disparities.
Sources
[1] Prop. 23 Asks: Should Dialysis Clinics Always Have A Physician On Site? (Schwartz et al., KQED)
[2] DPC Opposes California Prop 23 which Threatens Patient Access to Care (Dialysis Patient Citizens)
[3] Patients, providers struggle with ways to improve dialysis in rural areas (Kraus et al., Nephrology News & Issues)
[4] Dialysis Availability in Rural America (Martin et al., South Carolina Rural Health Research Center)
[5] For Black and Brown Kidney Patients, There Are Higher Hurdles to Care (Arnold et al., Scientific American)
[6] Rural and Micropolitan Residence and Mortality in Patients on Dialysis (Maripuri et al., Clinical Journal of the American Society of Nephrology)
[7] Twenty years of evolving trends in racial disparities for adult kidney transplant recipients (Taber et al., Kidney International)
[8] Kidney Dialysis Is a Booming Business — Is It Also a Rigged One? (Arnold et al., Scientific American)
[9] Effect of daily hemodialysis on depressive symptoms and postdialysis recovery time: interim report from the FREEDOM (Following Rehabilitation, Economics and Everyday-Dialysis Outcome Measurements) Study (Jaber et al., American Journal of Kidney Disease)
[10] Intensive Hemodialysis, Left Ventricular Hypertrophy, and Cardiovascular Disease (McCullough et al., American Journal of Kidney Diseases)
[11] Improving Peritoneal Dialysis Access in Rural Communities with Telemedicine (Brauer et al., Telehealth and Medicine Today)
[12] A heavy burden: Should dialysis rules be up to voters? (Ibarra and Ana, CalMatters)
Dorothy is a fourth-year Environmental Science major at UCLA and is a THINQ 2020–2021 clinical fellow.
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