Friday, September 2, 2011

Playing Ping Pong with Desperately Ill Undocumented

22 patients with kidney failure, most of them undocumented immigrants, are being ping ponged between Grady Hospital, a huge safety net facility in Atlanta, and Fresenius, the world's largest provider of private dialysis services.

Grady has been serving the poor in Atlanta since 1892. A quarter of Georgia’s physicians have had at least part of their training at Grady. The hospital has 953 beds. The Grady Health System, which includes nine neighborhood health centers, does 921,000 outpatient visits per year, but it has been in teetering on the edge of bankruptcy for many years.

In October, 2009, Grady closed its dialysis clinic, which was losing $2.5 million each year. The undocumented, who were a majority, are not eligible for Medicare. Grady was able to make other arrangements for some, and a small number agreed to return to their country of origin, with Grady providing time-limited support for continued dialysis.

For the remaining patients, Grady contracted with Fresenius for a one-year extension of dialysis services. In August 2010 the contract was extended for another year. That contract ended on August 31. Grady is facing a $20 million shortfall, and the parties haven't been able to agree on another extension. Fresenius has turned them away. Grady is trying to send them back. The patients are in limbo, and for the moment will have to wait until their condition deteriorates enough to require emergency dialysis. (See here for a discussion of how the emergency dialysis issue plays out in Texas.)

Grady and Fresenius are pointing fingers at each other:
"They are Grady patients,” [Fresenius] said. "While we are very concerned by the situation this places the patients in, the patients must seek treatment from Grady." Fresenius anticipates worldwide net income of more than $1 billion this year.

[Grady] responded indignantly. "There cannot be a debate about one thing. This group of patients has been under the care of Fresenius and their doctors for two years. If Fresenius decided to discharge a patient because they are unable to pay, that is Fresenius’s decision, having nothing to do with Grady."
Continuing to cover continued dialysis wouldn't be a big deal for Fresenius. But it would turn Fresenius into a safety net organization, and private providers would avoid contracting with public facilities in the future, for fear of being left with patients the Gradys of the world would stop paying for.

The problem is global, not local. It needs to be kicked up to the federal level. We should 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.

(Kevin Sack of the New York Times has tracked this story since 2009. See here for his latest report.)

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