The recently announced partnership of DaVita and the Kingdom of Saudi Arabia is a great opportunity to work together with an outstanding healthcare-delivery system to improve the health of its citizens. Kidney disease is an emerging public health concern in Saudi Arabia, as it is in the United States. DaVita is honored to be able to bring our knowledge and experience to enhance what is already excellent care, as well as to continue learning how best to improve care for kidney patients. This is truly a winning situation for DaVita, for Saudi Arabia and for kidney patients.

Read on below for more details on this partnership.

Left to right: Vice Minister of Health and Health Affairs, Dr. Mansour Naser Al-Howasi, Charge d’Affaires, U.S. Embassy in Riyadh, Tim Lenderking, Minister of Health, Dr. Abdullah bin Abdul Aziz Al Rabeeah, Chief Operating Officer of DaVita HealthCare Partners, Dennis Kogod.

Read more…

Every March National Kidney Month comes around, and every March I wonder how it is that the eighth leading cause of death in this country still hasn’t achieved the public recognition and awareness level of other killers, like heart disease, cancer, stroke and diabetes. It seems we could save so many lives and avoid so much suffering if the general public knew even the most basic information about kidney disease and its risk factors.

But the somewhat frustrating truth is that when I talk about what I do professionally with nonmedical people, I frequently hear the question, “What’s dialysis?” People generally seem to know they have kidneys and know they’re important, but have no idea why.

There’s so much health-related information available—so many conditions clamoring for funding and recognition—that it may all be too much for the modern consumer to digest.  Frankly, there are so many ribbons representing advocacy for various disease states that no one seems to know which color goes with which illness anymore. For example, the ribbon for kidney conditions is green, but so are the ribbons for bipolar disorder, celiac disease, scoliosis, cerebral palsy and Tourette syndrome, to name a few. Read more…

A recent editorial in the New York Times described a move by the New York City public hospital system to “pay doctors based on how well they perform.” (1) Under this program, the more than 3,000 salaried doctors at the NYU School of Medicine, the Mount Sinai School of Medicine and the Physician Affiliate Group of New York will receive no cost-of-living increases for the next three years, but there will be annual bonuses tied to meeting quality-performance goals. In the same issue of the Times there is an important critique of the pay-for-performance (P4P) approach, describing what many policy experts have said for years: “If only it worked.” (2) Op-ed columnist Bill Keller points out that the real driver of costs in our healthcare system is not overutilization of services, but rather the high unit cost of each service. Others may debate this premise, but the reality is likely a bit of both—more units and higher cost for each. As Bill Clinton said during the 2012 Democratic National Convention, “it’s math, folks,” and P4P is unlikely to change these factors significantly. Read more…

My last blog used the infamous Rodney King episode in Los Angeles as the springboard for suggesting that integrating care—physicians, hospitals and patients working together—is essential to achieve the best clinical outcomes for the chronically ill while constraining the runaway costs of healthcare. A recent article in The New York Times (http://www.nytimes.com/2012/12/25/opinion/approaching-illness-as-a-team-at-the-cleveland-clinic.html?_r=0) makes it clear that this is not a theoretical concept. Physicians at one of the great healthcare organizations in the country, the Cleveland Clinic, have been forming focused teams that can mobilize to efficiently diagnose and treat a variety of illnesses, including neurological, cardiovascular, oncologic, urologic and nephrologic. Read more…

DaVita is entering the world of international dialysis in a big way. We are partnering with doctors in Singapore, India, China, Malaysia, Saudi Arabia, Germany and other countries. As we embark on this exciting adventure, we again are faced with the nagging perception that dialysis outcomes in the United States are worse than those in other parts of the world. Two recent articles provide fascinating perspectives on this important issue. Read more…

I recently had a chance to round on some in-center dialysis patients at my facility at UCLA. It was incredibly heartwarming to see so many of my former patients still doing so well. It was a real homecoming for me. As I made rounds with Fellows and the entire interdisciplinary team, I started to reflect on what it meant to be a leader in a complex healthcare-delivery setting. There is no setting in medicine that better reflects the need for leadership than care in the dialysis facility. So what are the components of a true leader—things we never learned in medical school, but that are so critically important for our patients as we serve as leaders in dialysis facilities? Each person needs to determine what he or she truly believes struck a chord. Our leadership is based on our belief in truth, grace, growth and freedom. Beliefs determine behavior that defines performance as a leader.

Truth involves standards, honesty, discipline, integrity and clear expectations; grace is not a religious reference but includes showing others that you are on their side, that you have empathy, compassion and understanding; growth is characterized by demanding feedback, being self-aware, understanding others, and having humility and discipline; freedom means being encouraging and secure, and forgiving and empowering others—it leads to serving others, and true power comes from giving power to others.

You need to define what you believe as a leader, but these are right on for me. To be true to yourself, evaluate your leadership: 1) The gap: how far are you from where you want to be?; 2) The fit: how do I fit my role?; 3) Feedback: what do others say?; 4) Parallel context: how are others in similar roles doing?

Sound like a business-school exercise? Sound irrelevant to the day-to-day grind of a nephrologist/Medical Director? Think again. Leadership is demanded of nephrologists, and such leaders will not only have great dialysis facilities with incredible patient outcomes, but will also have successful practices and fulfilling lives.

One of the great things about DaVita is the incorporation of core values into everything that is done in the organization. As I made rounds I had a true epiphany—the way I conduct myself is exactly the articulation of the DaVita core values! I first and foremost am committed to enable high quality of care by serving my patients and delivering service excellence. To be a true leader and be trusted by colleagues and patients and their families, this service excellence must be delivered with the greatest integrity; we say what we believe and we do what we say. Delivering credible, excellent care cannot be done by one individual, but requires a team working together with a common vision to improve the lives of patients with kidney disease. We must, of course, never be satisfied with where we are, but rather must always strive for continuous improvement. We also must be humble and understand that none of us is always right, and we must be willing to ensure that accountability for one’s own actions is something we insist upon from our colleagues and our patients. If we can drive excellent service, in a transparent way with full integrity, working with a team, continuously improving and holding ourselves accountable, then we can experience true fulfillment while still having fun in the process. Is this an achievable vision? I would submit yes—I am living it!

So, stepping up and being a leader, while always anchored by fundamental core values, is for me the way to do the best I can for my patients and to live the most fulfilling life possible. Are you a leader? What are your core values? Take some time to answer those questions. It might just be the most valuable time you have spent in your hectic life as a nephrologist.

Remember what the great management guru Peter Drucker said:

“The leaders who work most effectively, it seems to me, never say ‘I.’ And that’s not because they have trained themselves not to say ‘I.’ They don’t think ‘I.’ They think ‘we’; they think ‘team.’ They understand their job to be to make the team function. They accept responsibility and don’t sidestep it, but ‘we’ gets the credit…. This is what creates trust, what enables you to get the task done.”

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

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My wife is a maniacal exerciser. Three days a week at the gym, weights and cardio; two days a week, Pilates; Saturday, walk on the beach with a girlfriend; Sunday, walk on the beach with me. Although she comes from a family of women with osteoporosis, she has incredible bone density.

Two weeks ago, we were in Santa Barbara visiting our niece, her husband — a postdoc at University of California–Santa Barbara — and their beautiful five-month old daughter. After a wonderful visit, we took off for a relaxing lunch and stroll in Carpenteria, a few miles south of Santa Barbara on the way home to Los Angeles. We were walking around the main drag when my wife turned to point to a cute shop, tripped, and hit the ground. Her foot immediately began to swell, so we got some ice for the one-hour drive home.

Over the weekend, we treated the foot with ice, heat and liberal painkillers, but by Sunday night we knew that we would need to see an orthopedist for an examination and x-rays. That is when it began to get really painful.

On Monday morning, I contacted the chief of orthopedics at a nearby hospital who had his assistant squeeze my wife in to see someone at noon that day. The administrative assistant who made the arrangements couldn’t have been nicer, and we felt like we were on our way to a resolution. We drove to the new state-of-the-art facility. It was a blustery day, and we had been told that we should drive up to valet parking so we could get a wheelchair to take my wife to the appointment. When we pulled up, the valet said, “Sorry, the garage is full.” I insisted that I needed to help my wife to the appointment; after consulting his colleagues, the valet came back with a ticket and took the car.

We walked to the bank of patient elevators, about a block inside the building, rode to the second floor and arrived to find out they had no record of the appointment. I called the administrative assistant who had made the arrangements, and she got that straightened out: “computer malfunction.” Next was the foot x-ray, with the patient having to navigate two large, heavy doors while holding a “patient notification pager” to get from the waiting room to x-ray. We saw a senior orthopedist, who diagnosed a Lisfranc fracture after the examination and review of the films. He thought an MRI should be done to better see the tendons and determine if a cast or surgery would be best. He wrote the order but said we would get a call in a day or two after the authorization was obtained.

By Wednesday, we hadn’t heard from the office and called — we were told they had the request but only one person in the office was authorized to interact with insurance companies, and she was out. Needless to say, after two additional days of pain and essentially no treatment, my wife was outraged. The office said they would see what they could do and would call us back. We called again on Thursday, and they said that the “insurance person” was still out; the one on the phone said it was not her job, but she would see if she could help and would return our call. When we called Friday morning, after not hearing from anyone on Thursday, we were agitated but glad to hear that the MRI had been authorized. We were instructed to call radiology for an appointment.

When we called, radiology said the earliest appointment was for the following Monday. We were incensed — a painful, though admittedly not life-threatening injury, and another several days before the needed test so that the correct treatment could be started. I again called the chief of orthopedics, and the administrative assistant called back in five minutes to say we could get the MRI at noon that day.

We were grateful, and my wife had a friend take her to the test. After it was completed, she asked the technician to please have the radiologist call the orthopedist with the results as soon as they were ready. He stated that the test was not marked “stat” and would be read the following Monday. When my wife went up to the desk to ask the radiology administrative assistant how to get this expedited, the assistant was sitting at the desk, eating lunch, and said, “There is nothing that can be done. It’s not marked stat, and only the ordering doctor can change that.” A final call to the chief of orthopedics, the MRI was read, and it showed not one but two fractures and the possible need for surgery.

No one could make up a story such as this, but it is all too common in our current healthcare system. None of the individuals involved in my wife’s care was hostile, rude or uncaring. They were all working within a system, however, that does not place value on being patient-centric. Like most of our care delivery system, perhaps with “elite” private and academic health centers the poster-children, it is more about “them” than it is about “us” when we are patients. Building beautiful new facilities and having the latest technology has little value when the system forgets why it exists — to provide compassionate, timely, high-quality care for individuals who are in pain, frightened and at the mercy of the system.

By the way, the fact that I was able to “pull strings” to accomplish even what was eventually done is not something of which I am proud. Like any husband, I was willing to do all that I could to make sure my wife was cared for in the best way possible. I am no different from any other husband, wife, son or daughter who wants only the best for their loved one. No one deserves anything less.

We should always remember that as physicians and healthcare workers, we are here to serve patients. As the founder of modern nursing, Florence Nightingale, said more than a century and a half ago: “Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion.”

Apollo 13 returned from moon orbit safely, and I hope we have the wisdom, foresight and ability to work together in teams to rescue our ailing healthcare delivery system.

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

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We have to admit — we are coming late to the party! The concept of a culture of safety began outside of healthcare in organizations that self-characterized as “high reliability,” where highly complex and often hazardous activities are a daily reality. Such organizations live and breathe safety from the senior executives to the frontline workers. The Agency for Healthcare Research and Quality (AHRQ) suggests that the following are key features of a successful culture of safety:1

• Acknowledgment of the high-risk nature of an organization’s activities and the determination to achieve consistently safe operations
• A blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment
• Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
• Organizational commitment of resources to address safety concerns

There are national efforts ongoing outside of AHRQ to address safety in healthcare, most notably the National Patient Safety Foundation (NPSF).2 This independent, nonprofit organization was established in 1997 and continues to provide programs to assist organizations in focusing on safety in healthcare. In 2006, a survey was conducted, led by the Renal Physicians Association (RPA), to get insights from patients and professionals on the state of patient safety knowledge and programs in ESRD/dialysis. This effort culminated in an ongoing website, Keeping Kidney Patients Safe, which is a fantastic resource in this area.3

Through the survey mentioned above, key areas of focus were identified, including hand hygiene, patient falls, incorrect dialyzer or solution, medication omissions or errors, non-adherence to procedures and venous needle dislodgement. Clearly, these are important issues of patient safety, and there are likely others that need attention as well. Missing from this list, however, are provider safety issues such as needle punctures. With the shrinking workforce in dialysis, keeping our colleagues in the dialysis facility safe is also an important imperative.

So, how do we implement the culture of safety in our facilities? By making a commitment as nephrologists and medical directors to make this a core part of how we function. The American Association of Kidney Patients (AAKP) has tried to get the patients involved in the effort with their national program, 5 Steps to Safer Health Care, described by Dr. Alan Kliger:4

• Speak up if you have questions or concerns
• Keep a list of all of your medications
• Make sure you get the results of any test or procedures
• Talk with your doctor and healthcare team about your options
• Make sure you understand what will happen if you need surgery

We need to make a commitment as we enter 2012: Establishing a culture of safety in our facilities will be a great gift for our patients and our staff, and we will make it happen! To do this successfully will require reassessment of the systems of care we currently have and a willingness to make the necessary changes.

As recently stated by Dr. Paul Batalden (and possibly attributable to W. Edwards Deming and/or Donald Berwick) of Dartmouth Medical School and the Institute for Healthcare Improvement (IHI):

“Every system is perfectly designed to get the results it gets.”

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

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References:

1.    http://psnet.ahrq.gov
2.    http://www.npsf.org
3.    http://www.kidneypatientsafety.org
4.    http://www.aakp.org

As an avid Kindle reader and someone who is often an early adopter of new technology, I was delighted to see the announcement recently that the Kindle Fire had arrived and would be an innovative addition to the growing field of e-readers and tablet electronic devices. Look out, iPad! New innovation drives more and better ideas, right? Innovative thinking results in more choices and a true push for value. This is the American way!

Nephrology has been left in the dust of innovation. Let’s take in-center hemodialysis and the technology to deliver it. Have there been substantive improvements in available equipment during the past decades, or have they been incremental? Is there competition among manufacturers sufficient to drive creativity, or is it just nibbling at the margins?

How about home dialysis therapy? Peritoneal dialysis (PD) is still performed the way it was developed more than 30 years ago with limited new approaches or technology. For home hemodialysis, equipment was created specifically to address this need. But wouldn’t it be even better if there were competitive products from which to choose that provided different features and pricing?

The lack of innovation spills over into the necessary pharmaceuticals that patients on dialysis need. Life-enhancing and clinically important medications — such as erythropoiesis-stimulating agents (ESAs), calcimimetics and others — have driven improvements in patient outcomes, but the lack of innovation and high development costs are particularly problematic in an age when publicly funded healthcare, not to mention the overall economy, is in serious trouble.

Innovation in medicine overall and nephrology in particular not only involves technology and medications but also care delivery models. Nephrologists are embedded in a fee-for-service reimbursement system that rewards individual care interactions and inhibits attempts to consider patient needs holistically. In addition, the ability to invest in proactive care that drives health rather than treating episodes of disease is severely constrained.

If at the end of the day we physicians must step up as true advocates for our patients and drive the best outcomes while stewarding the precious public funds (and trust), we need to advocate for:

     1.    Creating incentives for device and pharmaceutical manufacturers to want to innovate in the area of chronic
            kidney disease (CKD).

     2.    Easing the barriers that keep innovative equipment and medications that are widely used elsewhere in the world
            from being brought to the United States.

     3.    Aggressively pursuing creative care delivery models that include integrated and holistic care and an alignment
            of clinical and financial incentives.

     4.    Promoting collaboration with appropriate federal agencies to ensure that the comparative effectiveness of new
            delivery approaches, devices and pharmaceuticals is assessed, and when a new approach is demonstrated to
            add value, it is approved and appropriate reimbursement for its use is established.

As the innovator and philosopher Buckminster Fuller said, “You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.”

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

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I belong to a group of Chief Medical Officers that meets quarterly to discuss current and future challenges in the healthcare system.  The CMOs represent a wide variety of healthcare organizations, including integrated care systems, pharmaceutical companies, insurers, laboratory and pharmacy providers, and multispecialty physician groups.  I am the sole CMO from a chronic disease provider organization.  We recently met with Mike Leavitt, the former governor of Utah and former secretary of Health and Human Services under George W. Bush.  Mr. Leavitt is currently founder and chair of Leavitt Partners, a consulting firm in healthcare.  This was an intimate session with 10 or so CMOs participating with Governor Leavitt, and I was impressed with his view of the future of healthcare over the next four to six years.  The key points include the following — I have added what I see as the direct relevance for the future of kidney care:

1. Shift from compassion to dispassion. With the global economic crisis, including the serious economic downturn in the United States, dispassion (NOT the opposite of compassion) is becoming the decision driver rather than compassion.  Countries realize they cannot do everything for everyone.  In the United States this means that “good enough” will become an important part of the construct of healthcare delivery.
   Relevance for kidney care: We need to start being far more proactive in determining who is really going to benefit from dialysis, as well as when to work with families and patients when ongoing dialysis is just not improving a patient’s quality of life.  End-of-life care/palliative care need to be addressed much more openly and aggressively.
2. Networks. One only needs to look at the airline industry to see that networks have become an essential way of doing business in order to survive.  The future of healthcare will depend on robust networks, and in order to play providers have to form them or be part of them.
   Relevance for kidney care: It is likely that continued consolidation in the dialysis industry will occur, and will be required in the new healthcare world.  Survival as individual facilities or physicians will be increasingly difficult.  Should ACOs or other models of integrated care management continue to expand, nephrologists need to find their place in these networked organizations.
3. Buses, taxis and limos. Think of the city manager charged by the citizens to develop a public transportation system.  He decides taxis would be convenient and cost-efficient.  Over a few years, people in other cities hear about this, like it and move to the “taxi” city.  Soon the system is overloaded, more taxis are needed, taxes rise, and people start moving out or the wealthy stay but hire limos to continue to provide convenience.  The city decides, in order to provide transportation, it must switch to buses.  People complain, but the bus gets them where they are going.  In healthcare we are moving to getting from A to B, regardless of convenience — regionalized services, waiting periods and the like will all be necessary in a world of growing demand and increasingly limited resources, unless consumers pay for the level of convenience they want.  The question is can quality NOT be tiered despite tiering of convenience?
   Relevance to kidney care: Nephrologists are the gatekeepers of quality.  This responsibility cannot be delegated to other entities.  This will be increasingly important as more and more care will be “good enough”.  Nephrologists must be part of such discussions and always continue to advocate for what is best for their patients.
4. Three competitive entities. These are large multi-specialty groups, insurers and hospitals.  None of the three has all of the ingredients, and the real question is who is the “general contractor” for the healthcare delivery in a city or region.  General consensus is that of the three, hospitals have the least clue and have been the least innovative in preparing for the new world.
   Relevance to kidney care: Be wary of aggressive moves by hospitals to acquire practices or tie nephrologists into exclusive agreements.  This sector of the industry seems the most “dinosaur-like,” and maintaining agility in nephrology practice is one of the key ingredients to continued success.
5. Cinderella and the ball. Speed and timing will mean everything in determining winners and losers.  The smart players will be inching toward the door of the ballroom at about 11:50 p.m. so that they beat the stampede to the midnight pumpkins and get trampled in the process.  The movement toward integration of the care systems is moving more rapidly than most people think.
   Relevance to kidney care: It is essential that nephrologists stay educated on the moving playing field of healthcare in general and nephrology in particular.  Know who the leading players are, and be prepared to initiate a partnership/collaboration when the stars align — in this case, early in is likely to be the best approach, if you have the right partner.
6. Kodak moment. Kodak had the dilemma of basing its brand on film, even as the world of digital photography was developing.  It was promoting the latter while still basing its core business on the former.  The winners in the new care paradigm are those who have figured out what disruptive technology is coming and how to prepare for it.
   Relevance to kidney care: Nephrologists must be proactive in testing new approaches to delivering kidney care.  Such things as every-other-day dialysis, more frequent dialysis in-center and wearable devices are all talked about, and if they provide significant incremental clinical advantages, patients should have access to these.  The barriers of inadequate reimbursement, however, are real but starting slow, and demonstrating overall value (quality/cost) can push the curve substantially.
7. Leaven in the loaf. It is clear that the first target for realigning healthcare will occur at the state level with intense pressure on Medicaid programs to constrain costs for states that are in the midst of massive budget deficits.  This could be fertile ground for experimenting.  Insurance exchanges are likely to grow much more rapidly than initially thought, with employers moving employees into these systems to control costs and shift costs to the employee.
   Relevance to kidney care: Erosion of Medicaid programs will significantly wear down CKD and ESRD patient care.  Nephrologists must be proactive in their individual states to ensure that this vulnerable population is protected.  Similarly, insurance exchanges may significantly decrease fees paid to providers, threatening access of patients to care and the ability of nephrologists and dialysis providers to serve these patients.  An urgent threat is the omission of Medicare Secondary Payer (MSP) requirements for these exchanges, essentially resulting in patients with employer-based insurance being moved to Medicare immediately if they have ESRD rather than waiting the current 30 months.  As recently articulated by RPA/ASN/ASPN, “Patients with End Stage Renal Disease (ESRD) are among the most vulnerable of all Medicare patient populations. It is important to account for the needs of these patients by maintaining funding for ESRD care at current levels. The Medicare ESRD program was recently transitioned to a bundled payment system; the transition included an across-the-board payment reduction. Subjecting the program to further cuts would jeopardize patient access to readily available, high quality dialysis care. We urge you to consider applying the Medicare Secondary Payer (MSP) provision to the recently enacted health exchanges. This proposal not only will maintain current funding levels for ESRD care, but will also potentially achieve billions of dollars of savings for the Medicare program. ASN, ASPN, and RPA urge you to protect ESRD care by keeping dialysis reimbursements whole, and instead consider innovative solutions such as application of the MSP provisions to health exchanges.”*

As the hockey great Wayne Gretzky said, “You miss 100% of the shots you don’t take”.

This approach, and the urgency we and our patients face, is described in an African proverb:  “If you want to go quickly, go alone, if you want to go far, go together.” We have to go far, quickly, and that means we have to quickly find a way to change the world’s consciousness about exactly what we are facing and how we have to work to solve it.

Nephrologists need to look into the future, identify partners whose vision they share, and then together shape the opportunities for delivering even better care and better outcomes despite shrinking resources.

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

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*ASN, RSPN, RPA letter to Congress, October 13, 2011.