California Ballot Initiative Focuses on Dialysis Care

August 31, 2020 Updated: September 1, 2020

Every Monday, Wednesday, and Friday, DeWayne Cox, 57, visits the DaVita Valley Dialysis clinic in Van Nuys, California, where he has excess minerals such as potassium and phosphorus filtered from his blood.

A needle draws his blood, cleanses it through a machine, and then transfers it back into his body. This process of dialysis, which takes four to five hours each time, has been part of Cox’s weekly routine for the past 10 years.

Without it, Cox says he would die.

Proposition 23, also known as the Dialysis Clinic Requirements Initiative, would require at least one licensed physician to remain on-site during treatment at outpatient kidney dialysis clinics.

It also requires clinics to report dialysis-related infection data to state and federal governments. It prohibits clinics from closing or reducing services without state approval, and prohibits clinics from refusing to treat patients based on the source of payment for care.

The measure will be decided by California voters on the November ballot. If it passes, Cox says his life will be in jeopardy.

“It will cost clinics hundreds of thousands of dollars above their present budget, which is at the margins already. So that means they’re going to start closing up clinics or closing up shifts,” Cox told The Epoch Times.

While proponents say the measure increases the quality of care that vulnerable patients will receive by requiring a doctor to be present at all times, and would thus save lives, Cox says missing just one treatment could be fatal.

For some, when the public votes in November, life or death could hang in the balance.

Epoch Times Photo
DeWayne Cox visits the DaVita Valley Dialysis clinic in Van Nuys, Calif. (Courtesy of DeWayne Cox)

The Need for Treatment

Since he was diagnosed with kidney failure in 2009, Cox has struggled with his health, making a 9-to-5 job out of the question. A filmmaker by profession, he drives for Uber to make ends meet.

“Uber gave me that flexibility and film work is also something I do peripherally,” he said. “I had to have the flexibility to be able to go to dialysis three days a week.”

Cox said the process is difficult and it takes him a while to recover.

“When it’s taking out those minerals, it’s literally taking out energy. It’s draining my body … but I know it’s life-saving, so I do it,” he said.

Failing to miss even one treatment is out of the question. He made that mistake once—due to work obligations in 2017—and the consequences were dire.

“I missed a dialysis session on a Friday, and I ended up in the emergency room on that Saturday because of chest pains,” he said.

Once he was in the emergency room, the attending physician prescribed insulin, a misstep that landed him in intensive care for two days.

“They didn’t know what they were doing,” Cox said. “They did not know how to treat me there, unfortunately.”

Cox is concerned that added costs due to Prop 23 would reduce a clinic’s available hours of operation, potentially causing him to miss work for treatment.

“There are a lot of people who won’t be able to work because they have to go to dialysis—that’s the first priority. Or maybe, they’ll have to go to a clinic that’s much, much further away,” Cox says.

“And that leads to the possibility of missing sessions, and then situations like what I had to endure when I went to the emergency room. So that’s very dangerous for patients.”

Epoch Times Photo
An ambulance is parked outside a DaVita kidney dialysis center in Van Nuys, Calif., on Aug. 31, 2020. (John Fredricks/The Epoch Times)

However, Prop 23 would prohibit clinics from closing or reducing services without state approval.

The California Department of Public Health (CDPH) would have the authority to exempt a clinic from the mandatory physician requirement if there is a physician shortage or if at least one nurse practitioner or physician assistant is on site.

It’s this requirement that’s become a primary sticking point between supporters and critics of the initiative.

The Quality of Care

“Patients will experience better quality care and have better outcomes” when a doctor is present, says Steve Trossman, a spokesman for Service Employees International Union–United Healthcare Workers West (SEIU–UHW), which is sponsoring Prop 23.

“The initiative requires that clinics have a doctor on-site, which will have a major impact on all aspects of the operation—patient safety, hygiene, and help when there are medical emergencies,” Trossman told The Epoch Times.

Trossman said that while every clinic has a medical director, the director isn’t currently required to be on site. Furthermore, he said, nephrologists—physicians who specialize in kidney physiology and disease—are only required to see their patients at the clinic once a month.

Trossman pointed to “many quality of care deficiencies in dialysis clinics” across the state. He said state records show more than 5,000 deficiencies were found during clinic inspections between 2017 and 2020.

“At least 315 citations were issued for failure to ensure that the physician’s orders were followed,” Trossman said.

He gave the example of a citation at a clinic in Encino. There was a delay in notifying a physician there that a patient had elevated blood pressure. Because of that delay, the problem wasn’t addressed in time and the patient became unresponsive, was transported by paramedics to the hospital, and subsequently died.

He said the possibility of delayed notifications would be greatly reduced under Prop 23.

“The doctor will be able to respond to emergencies, such as cardiac arrest, bleeding, dangerous fluctuations in blood pressure, and other common problems associated with dialysis treatment,” Trossman said.

Epoch Times Photo
A sign is displayed in the window of a DaVita kidney dialysis center in Van Nuys, Calif., on Aug. 31, 2020. (John Fredricks/The Epoch Times)
Epoch Times Photo
A DaVita kidney dialysis center in Van Nuys, Calif., on Aug. 31, 2020. (John Fredricks/The Epoch Times)

“The physician will also oversee quality of care, make sure procedures are followed, and be able to consistently assess the overall condition of the patients and watch for signs of potential problems or decline.”

But John Hammes, a nephrologist in San Diego who’s been working with dialysis patients for 25 years, told The Epoch Times that the measures mandated by Prop. 23 don’t guarantee patient safety.

“The population [of dialysis patients] is chronically ill. They have a lot of comorbidities. They tend to get infections that are much more likely to be immediately life-threatening,” he said.

The process of dialysis itself “puts the patients at increased risk for complications and bad outcomes … the treatment is a poor substitute for normal native kidney function.”

Kathy Fairbanks, a spokesperson for No Prop 23, a coalition of patients, doctors, and others who oppose the proposition, told The Epoch Times that the measure doesn’t guarantee patients will receive specialized care.

“The physician on-site doesn’t even have to be a specialist in kidney care,” she said. “They don’t have to be a specialist in anything. All they have to be is an M.D., so it could be a podiatrist, it could be a dermatologist. That, to me, says a lot.

“This physician would not be administering dialysis. They would be in an administrative position. And it won’t improve patient quality,” she added.

Dr. Peter N. Brentan, the president of the California Medical Association, is cited on the website of No Prop 23 as saying, “Prop 23 would unnecessarily increase health care costs and make the doctor shortage worse for all Californians by moving thousands of practicing doctors into non-caregiving roles in dialysis clinics.”

The Cost

In a March 10 statement opposing the measure, the California Medical Association (CMA) pointed to an analysis by the Berkeley Research Group that estimated the mandatory physician requirement would increase treatment costs by $320 million annually.

As a result, almost half of the dialysis clinics in California would have negative operating margins, according to the CMA—forcing clinics to scale back hours or shut completely.

“It’s very, very expensive. If this physician position were helping improve patient quality, that would be one thing, but … it wouldn’t have any impact on quality, it would just increase costs,” Fairbanks said.

Trossman said SEIU-UHW doesn’t “believe this figure is accurate.”

The calculations don’t take into account “the existence of the medical director who is already paid by the clinic,” he said.

Patients Caught in the Middle

Hammes said he is responsible for anywhere from 70 to 100 dialysis patients at any given time.

“Nothing is free in this world,” he said. “They’re going to find that it’s no longer financially tenable to continue to operate certain clinics, and that’s going to lead to dialysis clinics closing. And that’s going to lead to a reduction in access to care.

“They’re also going to restrict hours for certain clinics for cost reasons, and that’s going to lead to people having less flexibility in terms of how they schedule their dialysis treatments.”

He said flexibility is key for his clients.

“Patients cancel treatments all the time. They reschedule, they have other clinic visits, some of them work. Some of them just don’t feel like coming on a certain day, so they reschedule.

“So to reduce that flexibility is going to reduce the number of treatments that are rendered, and it’s going to increase hospitalization. A large number of patients are going to get treated in the hospital, and that’s going to cost the entire system even more money.”

Fairbanks said, “Initiatives like these end up putting the patients in the middle. It’s the patients who now don’t have anywhere to go to get dialysis.”

For Cox, the possibility of his clinic closing or reducing its hours is deeply disconcerting. He says DaVita Valley Dialysis “is a lifeline.”

“The only anchor and the only thing that I could rely upon was my dialysis center being there and available for me,” he said.

“And for many people, it’s also a social network. And for a lot of these people, it’s their only social network. So I know how important it is to have those centers there and available to us, and I don’t want to see us lose even one of them.”