The following is a two part series on why undocumented immigrants with end-stage renal disease (ESRD) should be covered by Medicare. The first part focused on background of the current situation and can be found here.
My primary motivation for this blog post is to highlight the ethical and financial strain that current federal policy places on our nation’s safety net hospitals. I find it unreasonable that a minority of hospitals who already serve the most vulnerable populations are offered no financial support for treating undocumented ESRD patients. As EMTALA forces these hospitals to provide emergency treatment for kidney failure, the safety net hospital has no other choice. Additionally, many safety net hospitals (such as Grady) are located in states which have decided not to expand Medicaid coverage. As CMS reduces disproportionate share (DSH) payments to hospitals across the nation, the loss revenue will not be offset by any gains from an increased insured low-income population.
Few hospitals know this better than Grady Memorial Hospital, who has provided poor and essential care to the Atlanta community for over 100 years. Prior to 2009, Grady provided uncompensated care to these individuals through their outpatient dialysis clinic, but was forced to close due to consistent annual losses of $4 million (Faden, 2009). This decision was controversial because the hospital faced a system-wide $20 million loss, but understood closing the clinic would result in emergency department crowding, longer admissions and more fatalities (Sack, 2011). It was estimated that two thirds of the clinic’s patients were undocumented immigrants. In response to the closing, a group of undocumented immigrants filed a lawsuit against Grady, claiming the hospital was responsible for their treatment (Faden, 2009). Despite the immediate dismissal by Judge Ural D. Glanville of Fulton County Superior Court, the case gained national media attention and criticism. As a result, Grady was forced to strike a deal with Fresenius’s outpatient clinics, to pay $15,500 per patient per year for free dialysis treatment of 21 undocumented immigrants (Sack, 2011).
So the big thing is cost, I understand. If we provide routine dialysis treatment for undocumented immigrants with ESRD, it will be infinitely more expensive. Although popular, this sentiment is just plain false. In 1997, a Houston study examined and published the exact costs associated for undocumented immigrants receiving both types of dialysis at the same hospital (Hurley, et al., 2009). Due to the district’s funding change, the opportunity to comparatively analyze undocumented immigrants with ESRD receiving emergent dialysis (n=13), against those receiving routine dialysis (n=22) was available (Hurley, et al., 2009). New undocumented patients to the health system could only utilize unscheduled emergent dialysis visits, while those receiving routine dialysis three times weekly prior to change, continued as “grandfathered in” patients (Hurley, et al., 2009). The study compared patient utilization of hospital services, self-perceived satisfaction, and costs.
The results were strikingly clear and empowering for advocates of Medicare ESRD expansion. Findings showed the emergent care group spent more days as inpatients (162 vs. 10.1 days), required more blood transfusions (24.9 versus 2.2), more emergency department visits (26.3 vs. 1.4 days), more intensive care unit days (6.1 versus 1.5), more hospitalizations (12.8 versus 1.1) and reported greater physical pain with a lower level of physical function (Hurley, et al., 2009). Overall, the undocumented immigrants forced to receive emergent care had increased patient utilization of services and lower patient satisfaction. As a result, emergent dialysis ($284,655) cost 3.7 times higher than routine, outpatient dialysis ($76,906) (Campbell, Sanoff, & Rosner, 2010).
In this study, restricting the use of routine dialysis by undocumented immigrants with ESRD was an ineffective cost saving policy. Undocumented immigrants entering the emergency department were frequently admitted based on acute complications and comorbidities of renal failure. Due to their deteriorated condition, the policy increased utilization of expensive inpatient services and unnecessary testing. Emergent dialysis care was more often administered through catheters instead of arteriovenous fistulas or grafts, which are associated with greater rates of infection and mortality (Hurley, et al., 2009). The findings of the study depicted the confounding, negative impact of emergent dialysis treatment on the individual and society who bears the cost of the treatment.
Campbell, A. G., Sanoff, S., & Rosner, M. H. (2010). Care of the Undocumented Immigrant in the United States With ESRD. American Journal of Kidney Diseases, 181-191.
Faden, R. (2009). Denying Care to Illegal Immigrants Raises Ethical Concerns. Menlo Park: Kaiser Health News.
Hurley, L., Kempe, A., Crane, L. A., Davidson, A., Pratte, K., Linas, S., et al. (2009). Care of Undocumented Indviduals With ESRD: A National Survey of US Nephrologists. American Journal of Kidney Diseases, 940-949.
Sack, K. (2011, September 9). Deal Reached on Dialysis for Immigrants. The New York Times, p. A11.