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Sunday, 5 September 2010

Death Postponed for Safety Net Dialysis Recipients

Uninsured patients with kidney failure - especially undocumented immigrants - who would be dead without dialysis, are caught between the financial plight of safety net hospitals and the disgracefully rudderless U.S. health system.

In January I predicted that the problem, which first showed its head at Grady Hospital in Atlanta, would become epidemic. This week, a report by Kevin Sack, who has been following the story for the New York Times, showed how our society chips away at ethical problems without yet coming to grips with the root causes.

Grady, a prototypical safety net provider, was in deep financial trouble, and decided to close its dialysis clinic, which was losing several million dollars each year. But who would take on care of the patients? Leaving them to fend for themselves would violate the precept against abandonment. But continuing the clinic as it was would contribute to Grady's decline, which would lead to harm to other patients.

Grady encouraged undocumented immigrants to return to their home country by paying for air fare and three months of dialysis. But poor patients can't get ongoing dialysis in Mexico, where most of the undocumented came from. Ultimately Grady agreed to pay for dialysis for 38 remaining patients, most of whom are undocumented immigrants, at Fresenius, a German-owned, Fortune 500 dialysis company, until August 31.

It appears that a new agreement will forestall avoidable death for the 38. Fresenius has agreed to take on 5 as "charity cases." DaVita, another Fortune 500 dialysis company, will also take on 5. Emory University in Atlanta will take on 3. And, for the moment, Grady will scrape together funds to pay Fresenius, for continued care for the remaining 25.

This Rube Goldberg arrangement allows 38 chronically ill people to continue life-prolonging treatment, at least for now. But in a sloppy way it does more. A year ago, Grady Hospital owned the problem alone. Now it has two Fortune 500 companies and a leading University holding the problem with it.

In my January post I proposed a comprehensive approach to the safety net problem:
We need to convene a working group to scope out the dimensions of the problem and identify options for action. The ideal convener would be the Secretary of Health and Human Services (or her designate - perhaps the Assistant Secretary for Health). The Medicare End Stage Renal Disease Center would be a key participant, as would the National Association of State Medicaid Directors and safety net providers, perhaps via the National Association of Public Hospitals & Health Systems. Because a substantial portion of the patients who are put at risk by program closure are immigrants, the Office of Citizenship and Immigration Services should be represented. And, because programs sometimes try to send immigrants back to their countries of origin, largely in Mexico and Central America, the Bureau of Western Hemisphere Affairs in the State Department should have a voice.

This may seem like overkill for a problem that involves a relatively small number of people. But the values at stake are central to who we are as a country and to the way others see us. Abu Ghraib involved very few people, but for millions, at home and abroad, it is, and should be, a source of shame. It won't take many stories, photos and videos of dying people "dumped" back to their villages, to do the same.

The problem isn't an easy one. But we should not be leaving it to individual safety net programs to struggle on their own, either by swallowing what will ultimately be unsustainable debt or by taking emergency action based on an inevitably narrow perspective.
Nothing of the kind has happened since January. But the likelihood of our taking a comprehensive approach to the problem is improved by Grady having succeeded in involving DaVita, Emory, and Fresenius in sharing responsibility for its solution.

Ethical deliberation shows us the right direction to go in, but doesn't tell us how to get there. I hope I'm right that by sharing the problem with three powerful partners, Grady is helping us inch towards doing better by this group of 38 patients and those facing similar problems at other safety net sites.


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