00:00:00
This is the future of healthcare.
00:00:03
Oh. I'm sorry.
00:00:05
This is the future of healthcare.
00:00:08
If I was confused, it's because
00:00:10
according to the former CEO,
00:00:12
they have the same business model.
00:00:14
If I had 1,400 Taco Bells,
00:00:18
and 32,000 people who worked in them,
00:00:21
I would, I would be doing all the same stuff.
00:00:24
You may not have heard of DaVita,
00:00:26
but they're everywhere,
00:00:28
along with their biggest competitor,
00:00:30
Fresenius.
00:00:31
They're the biggest players in the dialysis market,
00:00:33
which you may not know or particularly care about,
00:00:37
but you should,
00:00:38
because more than likely,
00:00:40
you have a kidney inside of you right now.
00:00:42
And nearly 750,000 people a year
00:00:45
experience kidney failure.
00:00:47
While over half a million Americans
00:00:49
are currently receiving
00:00:50
the only treatment for kidney failure,
00:00:52
besides a transplant,
00:00:54
dialysis.
00:00:55
But taking a look at how the free market
00:00:57
ran wild on just this one organ of the human body,
00:01:00
can give us some insight
00:01:02
into the future of American healthcare.
00:01:04
They're doing a lot of things
00:01:05
that you might encourage a fast food restaurant
00:01:07
to do, like get a lot of patients
00:01:09
through the facility each day,
00:01:10
cut back on wages, cut back on costs.
00:01:13
Turns out that kidneys are a little different
00:01:14
than a Crunchwrap Supreme.
00:01:20
[Former Dialysis Patient]
I was scared because at that point
00:01:23
was when I realized
00:01:27
I can die on the chair,
00:01:29
and I won't even know it.
00:01:30
[Alec]
This is Carmen.
00:01:33
Because Carmen's kidneys didn't work properly,
00:01:35
she needed to show up to dialysis
00:01:37
several times a week just to stay alive.
00:01:40
For over a decade,
00:01:41
Carmen showed up week after week
00:01:43
so a machine could do what her kidneys couldn't,
00:01:46
clean her blood.
00:01:48
And for most of that time, the clinic performing
00:01:51
that lifesaving service was a DaVita.
00:01:54
Over time, Carmen had witnessed
00:01:55
the kind of cost cutting and decline in quality
00:01:57
many of us have witnessed
00:01:59
in retail, food and furniture.
00:02:01
In 14 years, the quality of care diminished
00:02:06
to the point where
00:02:09
patients were having to suffer needlessly.
00:02:12
They cut back on cleaning cost,
00:02:13
leaving bloodstains on the floor and chairs.
00:02:16
They took away the numbing medication Carmen used.
00:02:18
The needle sticks are incredibly painful.
00:02:21
But one of the most alarming trends
00:02:23
is short-staffing,
00:02:25
asking nurses and dialysis technicians
00:02:27
to do more and more.
00:02:28
You may think of dialysis
00:02:30
as something like a gentle blood draw,
00:02:33
but it's more like an all-out assault on your body.
00:02:40
Patients describe passing out,
00:02:42
losing dangerous amounts of blood,
00:02:44
nausea, and vomiting,
00:02:45
blood pressure spikes.
00:02:47
Is this just a normal part of dialysis?
00:02:49
High-speed, short treatment time,
00:02:53
high ultrafiltration rate dialysis,
00:02:55
causes cardiac disease,
00:02:57
plummeting blood pressure,
00:02:59
horrible quality of life.
00:03:00
[Alec]
This is journalist Tom Mueller,
00:03:02
who spent five years talking to over 100 patients,
00:03:05
workers, and kidney doctors,
00:03:07
to blow the lid on this industry.
00:03:09
It is, and I'm not exaggerating,
00:03:12
the most horrifying thing I've read in years.
00:03:15
And I asked him, what happens when you do
00:03:18
this kind of high-speed dialysis with not enough staff?
00:03:22
I've talked with Megallan Handford,
00:03:24
who's a former LAPD officer
00:03:26
who retrained as a dialysis nurse.
00:03:28
He said that at times as a nurse,
00:03:29
he had 17 patients that he was responsible for.
00:03:33
And his description of a day at the office
00:03:36
was like working in a MASH unit in a war zone.
00:03:39
It was, you know, someone's cramping here,
00:03:41
someone's coding here,
00:03:43
running from place to place.
00:03:44
More than once he described having to
00:03:47
put a deceased patient under a sheet
00:03:51
and continue treating everyone else
00:03:53
because there was just no other option.
00:03:55
You're just sitting there waiting to see
00:03:57
what emergency is going to happen.
00:04:00
I've bled out, and while I'm bleeding out,
00:04:03
there's a person across from me
00:04:06
that is alarming.
00:04:08
Who are they going to help first?
00:04:10
And it's not just DaVita,
00:04:12
for this story,
00:04:12
I spoke to Fresenius workers across California
00:04:15
who all described
00:04:16
the same kind of nightmare scenarios
00:04:18
Carmen experienced at DaVita.
00:04:20
Over the years, I believe it went from,
00:04:23
you know, care over profit
00:04:25
to, very quickly, profit over care,
00:04:28
to get as many patients as they can
00:04:31
with the least amount of staffing and hoping
00:04:34
that nothing happens.
00:04:36
On a bad day, I mean, you can get up to
00:04:37
seven, eight, nine patients with one technician.
00:04:40
A manager told one of my coworkers,
00:04:43
we were complaining because we were
00:04:45
short-staffed that weekend,
00:04:46
and nobody came to help,
00:04:48
and “oh well, nobody died.”
00:04:50
That was the response.
00:04:51
One of the nightmare scenarios
00:04:53
of dialysis is, the patient
00:04:55
is hooked to the machine,
00:04:57
they go to sleep, the needle dislodges,
00:05:00
and the alarm doesn't sound,
00:05:02
and they bled out.
00:05:03
That is something that I've heard
00:05:05
in my reporting numerous times.
00:05:06
My worst experience on dialysis
00:05:10
was one of the times when
00:05:13
I passed out.
00:05:14
When I came to, I had no idea
00:05:17
that that had happened to me,
00:05:20
and I was scared.
00:05:21
At that point was when I realized
00:05:26
I can die on the chair
00:05:29
and I won't even know it.
00:05:30
If they're understaffed,
00:05:32
you don't have someone watching you every minute,
00:05:34
so bad things happen in a short time.
00:05:37
One of the ladies
00:05:38
that I used to ride transport with,
00:05:40
I saw her walking to the scale
00:05:44
really wobbly and shaky.
00:05:45
Nobody was around to help her or able to help her
00:05:48
because they were running short-staffed
00:05:50
that day like usual.
00:05:51
So while normally
00:05:55
they will escort you to the scale,
00:05:57
that was not the case that day.
00:05:59
At the scale, she fell.
00:06:02
And then next thing you know,
00:06:03
the ambulance people are rushing in
00:06:06
and they're putting her in,
00:06:09
and they covered her head when they took her out.
00:06:11
[Former DaVita CEO]
If I had 1,400 Taco Bells,
00:06:13
I would be doing all the same stuff.
00:06:16
[Tom Mueller]
You have patients on an assembly line,
00:06:19
crammed in as rapidly as possible,
00:06:23
and as many shifts as possible,
00:06:25
to make the facility more profitable.
00:06:28
But even when you're trying to run dialysis
00:06:31
like an assembly line, things happen.
00:06:34
A patient's ride drops them off late.
00:06:36
An emergency happens.
00:06:37
And to catch up,
00:06:39
somebody has to cut their dialysis time short.
00:06:42
But here's the problem,
00:06:44
a doctor has prescribed
00:06:45
a certain amount of time
00:06:46
for each patient to sit in a chair
00:06:48
with a certain amount of blood
00:06:49
being pushed in, and out, of their system.
00:06:52
If I need five hours of dialysis and I'm
00:06:55
only getting four,
00:06:56
it's not cleaning my blood as much as it should.
00:06:59
Toxins can build up in my bloodstream,
00:07:01
making me sick.
00:07:03
One of the most unambiguous findings
00:07:05
of medical research in dialysis
00:07:07
over the last 30 years
00:07:08
is that shortened treatment times, shorten lives.
00:07:12
It's very straightforward.
00:07:13
Now, if a patient wants to cut
00:07:15
their dialysis time short,
00:07:16
they need to sign something called an AMA,
00:07:19
a document basically saying,
00:07:21
you want to do this against medical advice.
00:07:24
But at DaVita and Fresenius,
00:07:26
it's not always willing.
00:07:28
We would ask the patient to sign an AMA,
00:07:30
even though it's not the patient's fault,
00:07:32
but we have a schedule to keep with the next patient.
00:07:35
That's the fast food model of healthcare,
00:07:38
where the chains
00:07:39
want patients on that machine for 3 to 4 hours.
00:07:42
[Alec]
This is economist Ryan McDevitt,
00:07:45
who’s studied the business of dialysis extensively.
00:07:47
If a patient needs to be on the machine
00:07:48
longer today,
00:07:49
but they have another patient that’s supposed to come in
00:07:51
for their session
00:07:51
where they're gonna get another reimbursement,
00:07:53
they don't want to adjust the schedule
00:07:55
to accommodate that patient
00:07:56
who needs a more personalized type of care.
00:07:59
But here's the problem,
00:08:00
if you want one of the limited kidneys
00:08:02
available for transplant,
00:08:04
disregarding a doctor's order, looks really bad.
00:08:07
One DaVita patient I spoke to
00:08:09
claims she was turned down
00:08:10
for a kidney transplant, in part
00:08:13
because of these AMAs on her medical record.
00:08:15
A kidney transplant means
00:08:16
not being trapped in a chair for hours a week.
00:08:19
It means living longer.
00:08:21
But transplant organizations
00:08:22
don't want to give kidneys to people
00:08:24
that they feel won't follow a doctor's orders.
00:08:28
Another problem in the dialysis industry
00:08:30
is that the very system designed by Medicare
00:08:32
to keep clinics accountable
00:08:34
has been gamed by DaVita and Fresenius.
00:08:37
They have an incentive to push out patients
00:08:38
who are going to harm their scores,
00:08:40
and so [the] most glaring aspect of this
00:08:42
is when a patient is kicked out of a facility,
00:08:45
and they'll find different
00:08:46
nefarious ways to do that.
00:08:48
We've heard anecdotes where,
00:08:49
they'll trumped up charges on patient
00:08:50
and say they've been disruptive,
00:08:51
or that they’ve threatened staff,
00:08:53
but what it does is
00:08:54
help them look better on the report cards,
00:08:55
and that's important because
00:08:57
if they fall short
00:08:58
they will lose 2% of their Medicare reimbursements.
00:09:01
Another glaring example of juicing their scores
00:09:04
involves ambulances.
00:09:05
When a patient gets sent to the hospital
00:09:07
from the clinic,
00:09:08
it’s a sign something has gone wrong,
00:09:10
and so, it hurts your score.
00:09:12
My blood pressure shot sky high.
00:09:15
I mean really high.
00:09:16
I'm like, “shouldn't we be calling the ambulance?”
00:09:20
They're like, “no, we're going to get it down.
00:09:21
We'll get it down. We'll get it down.”
00:09:22
I'm thinking, if you don't get me to the hospital,
00:09:25
I'm going to have a damn stroke.
00:09:26
I never got an ambulance
00:09:30
until I put my foot down.
00:09:34
And I said, “either you call an ambulance or I will,
00:09:38
because I really don't give a damn
00:09:41
about DaVita’s numbers.”
00:09:43
I've actually heard an incredibly similar story
00:09:45
from another patient
00:09:47
at an entirely different DaVita location.
00:09:49
Allegedly, a man was repeatedly fainting while
00:09:52
another patient pleaded
00:09:53
with staff to call an ambulance.
00:09:56
[Ryan McDevitt]
Whenever there's a dollar at stake,
00:09:57
the for-profit chains do everything they can
00:09:59
to chase that dollar,
00:10:01
even if it comes at the expense of patient care.
00:10:03
Now, if you're wondering
00:10:04
why these patients
00:10:05
just can't go to another company for dialysis
00:10:07
instead of the emergency room,
00:10:09
well, DaVita and Fresenius have been on a buying spree,
00:10:12
and Ryan McDevitt studied
00:10:14
what happens when they buy up other clinics.
00:10:16
We use this quirk in Medicare data
00:10:19
where we could look at the same facility,
00:10:21
same patients.
00:10:22
Before and after DaVita and Fresenius took over,
00:10:25
hospitalization rates went up by about 6%,
00:10:28
death rates go up 3%,
00:10:30
and most alarming,
00:10:31
transplant rates for the patients
00:10:33
during their first year of dialysis
00:10:34
fell by almost 10%.
00:10:36
Now, you think, well, why would that be?
00:10:37
It seems to me
00:10:38
that if you want to maintain your cash flow,
00:10:41
you don't let people off dialysis.
00:10:43
That sounds a bit sinister,
00:10:45
but it just is a matter of incentives.
00:10:47
More alarming, is that when patients do push back
00:10:50
and advocate for themselves,
00:10:52
the consequences are sometimes dire.
00:10:54
In my experience as a reporter,
00:10:56
patients who speak out about their rights,
00:10:58
patients who are a little bit difficult,
00:11:01
patients who don't agree immediately to be
00:11:03
passive subjects of care
00:11:05
are quite often targeted for intimidation,
00:11:08
and sometimes pushed out of their clinics.
00:11:10
When you're pushed out of a clinic
00:11:11
as a dialysis patient, your lifeline is cut.
00:11:14
This fear has been a consistent
00:11:16
throughline in the history of dialysis.
00:11:18
In fact 25 years ago,
00:11:20
Republican Senator Chuck Grassley
00:11:22
held a hearing on dialysis
00:11:24
and couldn't find many patients
00:11:26
willing to go public.
00:11:28
He expressed his frustration by saying,
00:11:30
“They must dialyze to live.
00:11:32
That fact alone has discouraged
00:11:34
many patients interviewed by this committee
00:11:36
from coming forward today to publicly testify.”
00:11:39
Quite often because you've been discharged,
00:11:42
you're not accepted at other clinics,
00:11:44
you're blackballed in the area where you live,
00:11:46
so your last resort is the emergency room,
00:11:49
but emergency rooms aren't set up for chronic care.
00:11:52
So they don't actually treat you
00:11:54
until your blood is so toxic,
00:11:56
your whole physiology is so messed up
00:11:59
that you're about to die.
00:12:00
Of course, this yo-yo effect on the human
00:12:03
body is disastrous
00:12:05
and leads to, you know, rapid demise.
00:12:08
DaVita and Fresenius collectively today
00:12:10
own about 80% of facilities across the country.
00:12:12
They’ve systematically gone
00:12:13
and bought up over 1,000 independent clinics.
00:12:17
One way they've maintained this duopoly,
00:12:18
Ryan alleges, is by bribing kidney doctors.
00:12:21
[Ryan McDevitt]
They're paying kickbacks to nephrologists
00:12:23
to get them to refer more patients to the facility.
00:12:25
So DaVita and Fresenius have collectively
00:12:28
over a billion dollars in settlements and fines
00:12:30
over the past decade or so.
00:12:31
They view it as the cost of doing business.
00:12:33
For them it’s like paying the rent
00:12:34
or paying employees.
00:12:35
With their duopoly cemented,
00:12:37
DaVita and Fresenius have been able to aggressively
00:12:40
enshittify dialysis with no repercussions.
00:12:43
Sam and Manny have been organizing
00:12:45
with United Healthcare Workers
00:12:46
to fight for better pay and more staffing.
00:12:48
at Fresenius and DaVita.
00:12:50
Manny alleges Fresenius has been retaliating
00:12:52
against workers involved in unionizing.
00:12:54
Carmen is lucky.
00:12:56
She got a kidney transplant,
00:12:57
but she is still fighting for better
00:12:59
working conditions for the dialysis workers
00:13:01
that kept her alive.
00:13:03
They take care of us.
00:13:04
They're responsible my kidney.
00:13:06
My brand new kidney
00:13:08
is going to be two years old tomorrow.
00:13:10
If you have kidney failure
00:13:11
in the United States,
00:13:13
you're worse off than almost anywhere
00:13:15
in the developed world.
00:13:16
Patients in America die sooner
00:13:18
than anywhere else in the developed world.
00:13:21
They have a 20% annual mortality rate.
00:13:24
Compare that to Europe, which is 12 to 15,
00:13:26
compare that to Japan, which is 6%.
00:13:28
It's radically, radically different.
00:13:30
So American patients die 2 to 3 times faster.
00:13:33
The dialysis industry
00:13:34
strongly objects to the way Tom
00:13:36
characterized their business in his book.
00:13:38
They did so through lawyers.
00:13:39
I sent some of the stronger statements
00:13:41
to the major dialysis companies,
00:13:43
and some didn't answer, but others,
00:13:46
via their lawyers, wrote back and said, basically,
00:13:48
I was full of shit.
00:13:49
I was completely wrong about everything.
00:13:51
And to me, and to my publisher,
00:13:54
that was an attempt to block publication of the book.
00:13:57
They didn't say it in so many words, but
00:13:59
they suggested this was libelous.
00:14:01
In 2019,
00:14:02
before Ryan McDevitt's damning publication
00:14:04
about dialysis chains,
00:14:06
the editors of that journal received
00:14:08
a lengthy email from a DaVita executive.
00:14:10
It includes a laundry list of complaints that,
00:14:13
if true,
00:14:14
would likely have gotten the paper retracted,
00:14:16
according to McDevitt.
00:14:18
After he and his coauthors responded,
00:14:20
an editor called the complaints silly and confused.
00:14:23
The DaVita and Fresenius model
00:14:25
are not unique to dialysis.
00:14:27
They just have the perfect set of customers,
00:14:29
people who need to show up three times a week
00:14:31
or die in short order.
00:14:33
But hospitals, doctors offices,
00:14:35
pharmacies, even veterinary clinics
00:14:37
are being consolidated in similar ways.
00:14:40
That's one of the few things
00:14:41
that everybody can agree on,
00:14:42
right, left and center,
00:14:43
is that our healthcare system is broken,
00:14:46
and dialysis is just sort of
00:14:48
the worst case scenario of what can happen
00:14:51
when you totally focus on
00:14:52
profits and on Wall Street,
00:14:54
and turn the other cheek to human harm.
00:14:57
The model is the same,
00:14:59
buy up local businesses and aggressively cut costs.
00:15:02
It doesn't have to be this way.
00:15:03
Nearly every other country in the world
00:15:05
has figured this out.
00:15:11
Thank you so much for watching.
00:15:12
If you work in dialysis
00:15:13
or any other part of the healthcare industry
00:15:16
and have a story to share,
00:15:17
we'd love to hear from you.
00:15:18
Send us a line at stories@perfectunion.us.
