A Cluster Randomized Clinical Trial
Hidden Physician Financial Conflicts of Interest in Dialysis
Nephrologists’ Ownership Of Dialysis Facilities Doesn’t Affect Outcomes, But Why Is It So Secret?
Many U.S. nephrologists partially (or entirely) own dialysis facilities and refer their patients to them. Although these arrangements are legal, they create obvious financial conflicts of interest. Such ownership arrangements mean that nephrologists both receive professional (physician) fees for taking care of their dialysis patients and they receive a share of the dialysis facilities’ profits. However, physicians rarely disclose their ownership arrangements to their patients. The Centers for Medicare and Medicaid Services (CMS) pays for most of the dialysis care in the U.S. and does not systematically collect information about dialysis facility ownership. Given that these conflicts of interest may go undetected, our team studied whether nephrologist ownership of dialysis facilities affects patient outcomes.
There are two key takeaways from our recently published study on the “Association Between Nephrologist Ownership of Dialysis Facilities and Clinical Outcomes” in JAMA Internal Medicine. First, there is almost a total lack of transparency around nephrologist ownership of dialysis facilities; obtaining data for this project required a Freedom of Information Act (FOIA) request to CMS. Second, we found that nephrologist ownership of dialysis centers was associated with some improved outcomes, such as an increased use of home dialysis. Policymakers and nephrologists widely agree that home dialysis is underutilized in the U.S. Nephrologist facility ownership was also associated with decreased use of erythropoiesis-stimulating agents (ESAs), which are used to treat anemia, a common problem among patients on dialysis. However, we did not observe complications from lower ESA uses, such as more severe anemia or increased blood transfusions. Most importantly, we found that nephrologist facility ownership, compared to non-ownership, was not associated with worse outcomes. We also didn’t find any differences in most clinical measures (e.g., mortality, hospitalization, or transplant waitlisting rates).
Ownership of Dialysis Facilities Should Be Public Information
While our findings regarding patient outcomes were reassuring, the barriers to obtaining and analyzing the data were troubling. CMS should make dialysis facility ownership transparency a requirement in line with other medical financial conflict of interest requirements. Our study is the first research conducted in this area and it’s clear that additional studies are needed given the high prevalence of chronic kidney disease (CKD) and spending on end-stage renal disease (ESRD) treatments. Finally, regardless of patient outcomes, patients should have access to information about who owns their dialysis facility. These types of disclosures are typical in many other areas of medicine, and dialysis facilities should not be an exception.
The study, “Association Between Nephrologist Ownership of Dialysis Facilities and Clinical Outcomes,” was published on November 7, 2022 in JAMA Internal Medicine. Authors include Eugene Lin, Matthew McCoy, Manqing Liu, Khristina Lung, Derick Rapista, Jeffrey Berns, and Genevieve Kanter.
Assistant Professor, Medicine and Health Policy & Management, Keck School of Medicine of USC and the USC Price School of Public Policy
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