Kenneth A. Liss, DO
Editor’s Note: Scroll down for a response from one of the authors referenced in this column.
When I was thirteen or fourteen, I took an acquaintance’s side over my brother’s in an argument. Full of righteous indignation, I bragged to my father how I was sure I had the moral high ground and had done the right thing. That was ill advised at best. My father gave me a lengthy dissertation about the need to protect your siblings publicly even if privately you discuss otherwise. Needless to say, I regretted my decision for some time and it has stood as a powerful life lesson.
Recently a nephrologist used the pages of one of our most respected peer journals to question the motives of fellow nephrologists who participated in JV dialysis facility ownership. Let me be very transparent. I am part of just such an enterprise. I am also quite motivated by profits, and being able to earn an income that supports my lifestyle. In no way am I embarrassed by this fact. In fact, it is part of what made me study hard in school, go to medical school, and complete a renal fellowship. I now see an average of 20 to 30 patients daily while handling administrative details and teaching in a residency program. In addition, I have an active clinical research program and occasionally find time to opine in this editorial section. Paramount, however, is providing high quality compassionate care to my patients. Hopefully at the end of the day I can say that nothing stood in the way of this most solemn obligation.
Right now, there is a critical intellectual and political battle raging in America regarding the best path forward to provide quality care to all of our citizens. There is one school of thought that believes that profit needs to be removed from the delivery of this care. Nephrologists provide ESRD care for approximately one ninth of one percent of the US population, yet are responsible for eleven percent of Medicare costs. Certainly, we can provide invaluable insight into this debate.
I fear that the solutions are too complex, and they are definitely too varied, for this editorial section. I can assure you, however, that having our motivations and honesty questioned by one of our most respected thought leaders makes our task that much more difficult. Make no mistake, the purpose of that opinion piece was just that. Now I need to answer to my colleagues from other disciplines as to why I put my own avarice above the needs of the most vulnerable patients. Using a public forum to take one’s colleagues to task for doing their job is not only insulting but may be part of the reason why 40% of nephrology fellowship positions are not being filled.
The author of the same piece attacks ESRD seamless care organizations (ESCO) for the same conflict of interest issues. It is my understanding that those organizations profit when patients are best managed and avoid hospitalizations where a fee-for-service model is the major component of reimbursement. Those organizations profit when patients are managed efficiently and of course in a cost-effective manner. It is my opinion that an organization that does that successfully has every right to profit. Lastly we are led to believe that data comparing quality of care in joint venture facilities and non-joint venture facilities is nonexistent and furthermore impossible to accumulate. I welcome such a study and have extreme doubts that mortality in for profit and non-for profit facilities, even those that are a JV model, is dissimilar.
The truth is that most people choose their medical providers through recommendations from friends, relatives, or through word of mouth. This choice comes with some risk and as a medical practitioner I understand that this puts patients in a vulnerable position. I take quite seriously this responsibility and am therefore personally compelled to adhere to a certain code of conduct. Profit should be the end product of rigid standards, quality, and hard work whether you are a brain surgeon or a shoe cobbler. I would never work in any other system and I would never be so supercilious to publicly question anyone else’s motivation for doing the same. Perhaps take a lesson from my father next time.
Dr. Berns Responds
Without naming names, Dr. Liss recently took me and my coauthors to task for our editorial about joint venture arrangements between nephrologists and companies that provide dialysis treatments. Quite contrary to his primary premise, we did not question the motives of fellow nephrologists. In fact, we were very clear in stating that, “We make no allegations regarding quality of care or illegal or unethical practices by nephrologists or dialysis companies as a result of joint-venture partnerships.” We even acknowledged that there might be benefits for patients when nephrologists and dialysis companies are financially aligned.
But we should not lose sight of the fact that there is a robust body of evidence demonstrating that physicians’ judgment can be influenced by their financial interests. This is not because physicians are dishonest or because they intentionally pursue profit at the expense of patient care. It is because physicians, like all people, respond to financial incentives.
Patients with end-stage kidney disease are a particularly vulnerable population. The care they receive consumes a disproportionate fraction of healthcare dollars and generates tremendous profits for both the companies that provide dialysis and their joint venture partners. This isn’t necessarily a bad thing; we are all in favor of physicians being fairly compensated and don’t in any way oppose a favorable return on a joint venture investment.
What we argue for is transparency about joint venture arrangements and the opportunity to study the impact of these arrangements, whether positive or negative, on important patient outcomes and patient satisfaction. On this front, we seem to be in agreement with Dr. Liss, who says that he would also welcome such a study. Finally, since interest in nephrology has been declining for years, our editorial is clearly unrelated to the fact that many nephrology fellowship positions are vacant. This might be more related to perceptions among Internal Medicine residents that nephrologists are too focused on chronic hemodialysis to the exclusion of other areas of nephrology.
I suspect Dr. Liss’ father also taught him about doing what’s right. That is all my coauthors and I are asking for.
Jeffrey S. Berns, MD