For-Profit Dialysis Units Referring Less for Transplant?

F. Perry Wilson, MD, MSCE


September 11, 2019

Editor's note: Since the publication of this commentary, the referenced study has been retracted and republished. While the differences between for-profit and not-for-profit businesses remain, the magnitude of difference is less than what is discussed here.

Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I'm Dr F. Perry Wilson.

This week, try the following experiment: Find a nephrologist like me and ask, "What type of renal replacement therapy would you want if you needed it?" If any of them says anything except "transplant," I'll eat a cellulose semipermeable membrane.

That's because transplant is demonstrably the best therapy for someone with end-stage kidney disease. It's cheaper than dialysis, less burdensome than dialysis, and associated with longer survival than dialysis.

That's why it's so depressing to see this study[1] that appeared in the Journal of the American Medical Association, which found that in the United States, just 8.2% of 1.5 million dialysis patients were placed on the transplant waiting list.

Only 4.9% ever got a transplant. This is bad. But it gets worse.

The study, which spanned the years 2000 to 2016, took data from the USRDS (United States Renal Data System—a national registry of every dialysis patient) and linked them to two dialysis facility datasets. This way, the authors could look at these 1.5 million people and know what type of dialysis center they were in. As you can see below, the vast majority were treated at one of the two large national for-profit chains, with a smattering of patients treated at other for-profit units and a minority—just about 13%—treated at nonprofits.


Does it matter where you get treated? Apparently so.


Individuals receiving dialysis at for-profit chains were about 60% less likely to be put on the transplant waitlist than those at nonprofits. They were half as likely to actually get a transplant.

Pitchfork time? I asked senior author, Dr Rachel Patzer of Emory, whether the data showed that for-profit centers were potentially dragging their feet on transplant referrals in an effort to keep dialysis chairs filled.

Courtesy of Dr Patzer

No, it doesn't. But Dr Patzer was quick to point out that her study only captures a couple of steps in the transplant process.


It takes a lot of things to get a kidney transplant: educating the patient about transplant, agreement to the transplant process, referral for transplant evaluation, getting tons of tests to ensure that the individual is an acceptable candidate, and finally listing on the waitlist. And then, waiting; it's not like there's an unlimited supply of kidneys out there. Maybe centers are just referring their healthiest patients, considering that the likelihood of getting transplanted is pretty low, regardless.

Any of these points might explain the difference between nonprofit and for-profit centers. And while the evidence held up to adjustment for several factors, case mix may play a role here. In a sensitivity analysis, the authors looked at individuals who switched from a nonprofit to a for-profit center, and found that their rates of listing and transplant looked pretty much like a standard nonprofit-center patient.

In other words, there's more to the story. That said, it's clear that the financial incentives are currently misaligned, for both for-profit and nonprofit centers.

In a somewhat encouraging development, Health and Human Services Secretary Alex Azar has announced the Advancing American Kidney Health initiative, which aims to address some of these incentives, providing new payment models for getting your patients transplanted. The devil is in the details, of course, so we'll all be watching closely to see if the profit motive can be motivated toward transplant.


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