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July 9, 2014

DaVita Kidney Care Welcomes New Vice President of Clinical Affairs for Home Dialysis

DaVita Kidney Care’s mission is to be the Provider and Partner of Choice. To achieve this mission, we are continually recruiting top clinical leaders in nephrology research and clinical practice to join the DaVita Village. I am proud to announce that we have the honor of welcoming Martin Schreiber, M.D. to our physician leadership team as the vice president of clinical affairs for DaVita home dialysis and a member of the Office of the Chief Medical Officer. I have personally known Marty for more than 20 years and have seen how his commitment to clinical excellence has been a driving force throughout his nephrology career. He has devoted his life to improving the quality of care and quality of life for patients with chronic kidney disease, and is an internationally recognized clinician, researcher and advocate for home dialysis.

I am delighted to welcome Marty to the DaVita Village. My colleagues and I are excited to see such an exceptional physician have the opportunity to help lead the charge in delivering patient-centric care, enhancing patient choice and moving up the DaVita Patient-Focused Quality Pyramid.

February 1, 2012

Houston, We Have a Problem …

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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November 8, 2011

What Happened to Innovation?

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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