Editor’s Note: Seven propositions will be on the November ballot. The July 14 edition of the Idyllwild Town Crier had an article describing all seven propositions. Between now and the election on Nov. 8, the Town Crier will report on each proposition individually. In this edition is the fourth of these articles, Proposition 29, entitled “Protect the Lives of Dialysis Patients Act (2022).”
Proposition 29 includes several requirements affecting kidney dialysis clinics and the California Department of Public Health (CDPH) is tasked to implement adopting regulations within one year after the law takes effect.
Clinics are critical if a person’s kidneys begin to fail. They will need either a transplant or continual treatment — kidney dialysis.
The principal new requirement Prop 29 would impose is the presence of a physician, nurse practitioner or physician assistant on-site whenever a patient is receiving dialysis treatment. The on-site medical professional would be required to have six months of relevant experience. Exceptions may be granted if there are insufficient qualified people in the area. But a qualified medical professional would still have to be available through telehealth and the exception will last only one year.
Every three months, dialysis clinics would also be required to report infection data to CDPH. Prop 29 also requires clinics to identify any physicians who have a minimum of 5% ownership in the clinic. If this information is not reported, the owner or operator may be fined up to $100,000.
Patients may not have their treatment refused because of their insurance nor may clinics close or reduce services without state approval.
Most people with kidney failure receive dialysis at chronic dialysis clinics. Some hospitals provide the treatment and a few patients may receive dialysis at their homes.
According to the Legislative Analyst’s Office (LAO), about 650 licensed clinics are in California and they provide dialysis to about 80,000 patients each month. Since patients have different dialysis needs, such as length of treatment, clinics are often open six days per week and frequently outside of typical business operating hours.
DaVita Inc. and Fresenius Medical Care own or operate nearly 75% of California’s licensed clinics. Nonprofit organizations and smaller for-profit companies own or operate the other clinics.
Currently, CDPH is responsible for licensing and certifying these clinics. The certification enables the clinics to bill Medicare and Medi-Cal for payments.
Federal regulations, on which CDPH relies, requires a medical director/board-certified physician for each clinic. The medical director is responsible for quality assurance, including developing and implementing clinic policies and procedures, such as staff training.
To receive payments from Medicare, clinics must report specific dialysis-related infection information, such as when a patient develops a bloodstream infection and the suspected cause of the infection to the National Healthcare Safety Network at the federal Centers for Disease Control and Prevention.
Prop 29’s added staffing and reporting requirements will impose increased costs on clinics “… hav[ing] a physician, nurse practitioner, or physician assistant on-site during all treatment hours would increase each clinic’s costs by several hundred thousand dollars annually on average. Other requirements of the proposition would not significantly increase clinic costs,” according to LAO’s analysis.
Supporters of Prop 29 believe these are prudent requirements to protect extremely vulnerable individuals who are totally dependent on dialysis for life or until a kidney transplant can occur.
They argue that the presence of a physician, nurse practitioner or physician assistant is not currently required whenever patients are receiving dialysis, which can be a dangerous procedure. Expecting a doctor or highly trained clinician nearby is common sense if something goes wrong.
Since dialysis patients are prone to infections, reporting infection data to the state can identify problems to protect patients.
The opponents stress that the added costs will result in the closure of some clinics, thus endangering the lives of patients who live in those areas. Further, federal and state authorities already regulate and oversee dialysis clinics.
In response, supporters argue, the California dialysis industry spent over $100 million in 2020 to defeat another initiative regarding dialysis clinics. Also they dispute the opponents’ contention that dialysis clinics are already highly regulated. “They face far fewer inspections than other health facilities, and even so, deficiencies are often uncovered,” wrote supporters in the Official Voter Information Guide.
Thus far, California’s major newspapers — Los Angeles Times, San Francisco Chronicle, Orange County Register and the Sacramento Bee — have all published editorials urging readers to vote “No” on this proposition.
“For the third time in the past six years, California voters are being asked to weigh in on a seemingly obscure measure that would impose new requirements on in-state dialysis clinics — at the behest of the union that wants to organize these clinics’ workers. Yes, voters overwhelmingly rejected these measures in the past. Prop. 29 only makes marginal changes to the failed 2020 effort. Are Prop. 29’s changes significant enough to make the third time a charm? Not even close,” wrote the Register’s editorial board.
Two committees are actively promoting Prop 29’s passage. Service Employees International Union--United Healthcare Workers West (SEIU-UHW West) is sponsoring them both. At the end of June, both committees together had spent $11.7 million advocating approving Prop 29.
The committee opposed to Prop 29 had only expended $2.7 million fighting it as of June 30. However, it had $34.4 million in cash for the fall campaign. And since July 1, the committee has received nearly $50 million of which Davita Inc, and Fresenius Medical Care have contributed another $43 million.
In both 2018 and 2020, SEIU-UHW West sponsored previous propositions affecting dialysis clinics. In 2018, Prop 8 received 40% of the vote and in 2020, Prop 23 garnered only 37% of the voter. Both were defeated.