DVA – DaVita HealthCare Partners

[cubsfan]

I'm not sure anyone wants to try and sell you on DVA. What you call hard core rationalization, I see as conviction.

If DVA makes you uncomfortable, stay away for sure - there is plenty of uncertainty. Almost everything you have

raised has been discussed in detail. The low price compensates for the uncertainty in my opinion.

 

I don't see how this is a commodity service/business. There is a standard of care that is very important here.

Maybe narrow moat at best, as Fresenius is a high quality provider.

 

If politicians/gov change the rules on reimbursements to the negative there will be pain for sure. Just don't think

it will happen.

 

[sleepydragon]

I read some online stories by nurses who do dialysis. It's not that easy. New nurses make mistakes and some incidents are fatal. They need to well trained and guided by senior nurse. The work is very intense compared to working in the hospital, resulting shortage of workers. Also, nurses need special educations and pass tests, etc.. Anyway, my point is this is not a commodity business.

 

Maybe the issue here is DVA 's margin is capped. Its clients will never allow it to make excessive profits, nor will they want DVA lose incentives to open new centers. So DVA is like a regulated utility. But even with limited margin upside, current valuation is heavily discounted.

[JRM]

I'm not sure anyone wants to try and sell you on DVA. What you call hard core rationalization, I see as conviction.

If DVA makes you uncomfortable, stay away for sure - there is plenty of uncertainty. Almost everything you have

raised has been discussed in detail. The low price compensates for the uncertainty in my opinion.

 

I don't see how this is a commodity service/business. There is a standard of care that is very important here.

Maybe narrow moat at best, as Fresenius is a high quality provider.

 

If politicians/gov change the rules on reimbursements to the negative there will be pain for sure. Just don't think

it will happen.

 

Fair enough.  I've read through the entire thread.  Many of these issues were raised a while back.  As far as DaVita and/or Fresenius being high quality providers, why is it that costs are higher in the U.S. and patient outcomes are worse than other countries?

 

The service is very important, almost essential since not everyone can get a transplant.  However, that does not mean it is not a commodity service.  Antibiotics are essential as well.

 

Just seems like a tough way to make money to me. 

[JRM]

I read some online stories by nurses who do dialysis. It's not that easy. New nurses make mistakes and some incidents are fatal. They need to well trained and guided by senior nurse. The work is very intense compared to working in the hospital, resulting shortage of workers. Also, nurses need special educations and pass tests, etc.. Anyway, my point is this is not a commodity business.

 

Maybe the issue here is DVA 's margin is capped. Its clients will never allow it to make excessive profits, nor will they want DVA lose incentives to open new centers. So DVA is like a regulated utility. But even with limited margin upside, current valuation is heavily discounted.

 

I understand what you're saying.  But are these training/testing requirements that allow for a high barrier to entry (and high returns), or is it the duopoly created by Fresenius and DaVita using loopholes and exploiting private insurance?

 

I'm still trying to fully understand the moat and what would cause it to be lost.

[sleepydragon]

So CMS has already ruled that DVA cant proactively sign up patients to enroll in AKF. That resulted in only a small number of reduction in AKF patients

The battle ground now is if CMS will rule if AKF is outright illegal. If AKF is completed baned, yes that will hurt DVA badly. But will CMS ban AKF? Any thoughts?

[sleepydragon]

I read some online stories by nurses who do dialysis. It's not that easy. New nurses make mistakes and some incidents are fatal. They need to well trained and guided by senior nurse. The work is very intense compared to working in the hospital, resulting shortage of workers. Also, nurses need special educations and pass tests, etc.. Anyway, my point is this is not a commodity business.

 

Maybe the issue here is DVA 's margin is capped. Its clients will never allow it to make excessive profits, nor will they want DVA lose incentives to open new centers. So DVA is like a regulated utility. But even with limited margin upside, current valuation is heavily discounted.

 

I understand what you're saying.  But are these training/testing requirements that allow for a high barrier to entry (and high returns), or is it the duopoly created by Fresenius and DaVita using loopholes and exploiting private insurance?

 

I'm still trying to fully understand the moat and what would cause it to be lost.

 

Well, i think if even if u have a lot of money, you wont be able to start many dialysis centers that doesnt result in severe problems. The nurses are in demand, take times to train, and knowhow is important to run the center effienciently and nobody die.  Good luck trying to start one in CVS.

[JRM]

My wife works at a home infusion pharmacy.  It is a similar but different service provided by dialysis companies.  They have nurses that install PIC lines in patients and deliver IV drugs with pumps.  With the exception of hemophilia patients, the margins aren't amazing.  Even the hemophilia patients are not always worth the trouble anymore because of the competition to get these patients.

 

They have about a 60/40 mix of mediare/medicaid to private insurance mix; and they typically don't lose money on either.  I guess I see the dialysis business working this way with all things being equal. I am probably biased.

[rb]

I read some online stories by nurses who do dialysis. It's not that easy. New nurses make mistakes and some incidents are fatal. They need to well trained and guided by senior nurse. The work is very intense compared to working in the hospital, resulting shortage of workers. Also, nurses need special educations and pass tests, etc.. Anyway, my point is this is not a commodity business.

 

Maybe the issue here is DVA 's margin is capped. Its clients will never allow it to make excessive profits, nor will they want DVA lose incentives to open new centers. So DVA is like a regulated utility. But even with limited margin upside, current valuation is heavily discounted.

DaVita IS a commodity business. The reasons you've listed don't invalidate that. It doesn't matter how hard the work is. Let me give an example. Oil is a commodity business and Coke is not. But making oil is hard. I can't just go out there and produce oil. The work is very intense and you need lots of very expensive equipment and highly trained people. I can however make Coke. The process is easy and doesn't require much in terms of capital. These things don't change the commodity/not commodity aspect.

 

In the case of dialysis the equipment is commercially available, there are lots of nurses already trained and you can create/train more nurses. Yes it would take some time, but there are no barriers to making nurses. There is nothing proprietary here.

 

One thing that dialysis centres have is a sort of first mover advantage. It's hard to travel for dialysis so patients choose the centre closest to their home. On top of that there's not enough people with ESRD. So if you open another centre in an area that has an existing one I suspect that capacity utilization would drop so much as to make both centres unprofitable. That's typical of a commodity business and not really a moat.

[rogermunibond]

For the home infusion example it kind of depends whether the home care company is part of a health system or standalone.  There are ways that nonprofit hospitals can pad the hospital bottom line with buying infusion pharma products at discount and charging the insurer.  Likely wouldn't see the margin at the home care side but on the hospital books.

 

Don't think anything like that exists for DVA, but Fresenius manufactures GranuFlo and NaturaLyte which are used in dialysis.  They also have acquired generics and biosimilars biz.

[JRM]

For the home infusion example it kind of depends whether the home care company is part of a health system or standalone.  There are ways that nonprofit hospitals can pad the hospital bottom line with buying infusion pharma products at discount and charging the insurer.  Likely wouldn't see the margin at the home care side but on the hospital books.

 

Don't think anything like that exists for DVA, but Fresenius manufactures GranuFlo and NaturaLyte which are used in dialysis.  They also have acquired generics and biosimilars biz.

 

The idea for home infusion is similar to the dialysis business.  It is lower cost to the insurer to receive the infusions at home and it is more comfortable for the patient (usually).  The goal with both is to keep the patient out of the hospital as much as possible.

[MrB]

I read some online stories by nurses who do dialysis. It's not that easy. New nurses make mistakes and some incidents are fatal. They need to well trained and guided by senior nurse. The work is very intense compared to working in the hospital, resulting shortage of workers. Also, nurses need special educations and pass tests, etc.. Anyway, my point is this is not a commodity business.

 

Maybe the issue here is DVA 's margin is capped. Its clients will never allow it to make excessive profits, nor will they want DVA lose incentives to open new centers. So DVA is like a regulated utility. But even with limited margin upside, current valuation is heavily discounted.

 

I understand what you're saying.  But are these training/testing requirements that allow for a high barrier to entry (and high returns), or is it the duopoly created by Fresenius and DaVita using loopholes and exploiting private insurance?

 

I'm still trying to fully understand the moat and what would cause it to be lost.

 

Surely if one considers DVA/FSN to be "exploiting private insurance" one cannot simply gloss over the fact that they are not allowed to make money on 90% of their patients? DVA's revenue per treatment from government increased by 0.3% per annum over the last 10 years. Consider inflation and see the attached chart to get an idea of how long this has been going on. Virtually no other healthcare providers have been going without meaningful basket adjustments for so long.

Now for another exception. How come insurers can kick back patients to government after 30 months? It was set 12 months in the 1981, 18 months in 1990 and 30 months in 1997 and it came very close to being set at 42 months in 2007 (Bush vetoed it). Surely it is time for the commercial guys to step up too, because the last time they did was in 2007! However, the question is how valuable is the 30 months? The more I look into it the more I realise it is a significant number. So at the moment after 2.5 years the patient goes to government, right. Mortality rates are often quoted at around 20% which is also the number that sits behind the frequent statement of dialysis patients living 5 years. However when you look at the actual data from USRDS.ORG you note that 16% of your ESRD population is over 75 years old plus another 23% 65-74 old and the survival rate of those are naturally low. Only 8.3% and 1.9% respectively will live 10 years and longer, which tells you the majority of the often sited 20% mortality number is made up of 65 years and older patients. However survival of 10 years and longer jumps to 27% for 45-64 year old, 54% for 22-44 year old and 75% for your 0-21 year old. These last three age groups make up the 61% of your ESRD population and what you realise is that the ability to kick back these patients to government after 2.5 years is extremely valuable to private insurers. Just basic insurance logic tells you the biggest asset is a young healthy patient versus your biggest liability of a young sick patient especially if they have what looks to me to be the most expensive chronic disease in the system. BUT WHY is private afforded this extremely favourable financial treatment? From my understanding this is really the only disease where commercial is allowed to do this.

 

In terms of the AKF (still digging into this one), but up to 1996 healthcare providers were allowed to pay the roughly 20% shortfall in patients premiums (Medicare Part B and Medigap) directly. This practice was stopped by the 1996 HIPAA "act". At his point AKF stepped into the gap and started working with healthcare providers to pool contributions in order to provide financial aid to patients' uncovered dialysis costs. https://www.bridgespan.org/bridgespan/Images/articles/hngrb-american-kidney-fund/american-kidney-fund.pdf?ext=.pdf

At the time the frequently sited "Advisory Opinion" was received https://oig.hhs.gov/fraud/docs/advisoryopinions/1997/kdp.pdf

Context is important and here there seems to have been an evolution of industry practice over decades under regulatory scrutiny, so maybe its a bit simplistic to view it as some nefarious scheme cooked up over the last 5 years. 

 

P.S. How long will I live if I choose to stop dialysis?

This varies from person to person. People who stop dialysis may live anywhere from one week to several weeks, depending on the amount of kidney function they have left and their overall medical condition.

https://www.kidney.org/atoz/content/dialysisstop

 

Its complicated....hence the moat?

[MrB]

So CMS has already ruled that DVA cant proactively sign up patients to enroll in AKF. That resulted in only a small number of reduction in AKF patients

The battle ground now is if CMS will rule if AKF is outright illegal. If AKF is completed baned, yes that will hurt DVA badly. But will CMS ban AKF? Any thoughts?

http://www.npr.org/sections/health-shots/2017/02/14/515041363/texas-judge-upends-effort-to-limit-charity-funding-for-kidney-care

http://www.dialysispatients.org/sites/default/files/17-00016%20-%20Docket%20No.%2036%20-%20Order%20Granting%20PI%20%25282017.01.25%2529.pdf

[MrB]

My wife works at a home infusion pharmacy.  It is a similar but different service provided by dialysis companies.  They have nurses that install PIC lines in patients and deliver IV drugs with pumps.  With the exception of hemophilia patients, the margins aren't amazing.  Even the hemophilia patients are not always worth the trouble anymore because of the competition to get these patients.

 

They have about a 60/40 mix of medicare/medicaid to private insurance mix; and they typically don't lose money on either.  I guess I see the dialysis business working this way with all things being equal. I am probably biased.

 

The long term solution seems to be a re-balancing between government, commercial and providers. Government should pay a bit more, commercial a bit less and longer or a mix of the two and providers should make less. The main challenge to the industry is to transition without interrupting service delivery, because people's lives are at stake. 

 

Then...you have to address diabetes, hypertension and glomerulonephritis. Nothing is going to change unless the long term drivers are addressed.

 

[Spekulatius]

I read some online stories by nurses who do dialysis. It's not that easy. New nurses make mistakes and some incidents are fatal. They need to well trained and guided by senior nurse. The work is very intense compared to working in the hospital, resulting shortage of workers. Also, nurses need special educations and pass tests, etc.. Anyway, my point is this is not a commodity business.

 

Maybe the issue here is DVA 's margin is capped. Its clients will never allow it to make excessive profits, nor will they want DVA lose incentives to open new centers. So DVA is like a regulated utility. But even with limited margin upside, current valuation is heavily discounted.

 

I understand what you're saying.  But are these training/testing requirements that allow for a high barrier to entry (and high returns), or is it the duopoly created by Fresenius and DaVita using loopholes and exploiting private insurance?

 

I'm still trying to fully understand the moat and what would cause it to be lost.

 

It is a commoditized business in the sense that the treatment and the price they charge is standardized, but that is true for a lot of other medical treatments too.

 

They definitely need to operate with RN’s on the floor at all times and a doctor needs to be on call. as mentioned above, the quality of care is very important, most patients are very sick and their blood pressure and medication (Heparin, EPO etc) needs to be managed. Nurses need to be trained on the machines and the treatment and patients management and the work is quite intense as stated above, which in conjunction with the moderate pay results in considerable turnover. Mistakes on the floor can easily result in death of a patient.

This is certainly not a business that every idiot can run. FWIW, I don’t like the CEO and I think he has outlived his usefulnes, but he regards DVA as his baby (somewhat justifiable so).

[Foreign Tuffett]

I read some online stories by nurses who do dialysis. It's not that easy. New nurses make mistakes and some incidents are fatal. They need to well trained and guided by senior nurse. The work is very intense compared to working in the hospital, resulting shortage of workers. Also, nurses need special educations and pass tests, etc.. Anyway, my point is this is not a commodity business.

 

Maybe the issue here is DVA 's margin is capped. Its clients will never allow it to make excessive profits, nor will they want DVA lose incentives to open new centers. So DVA is like a regulated utility. But even with limited margin upside, current valuation is heavily discounted.

 

I understand what you're saying.  But are these training/testing requirements that allow for a high barrier to entry (and high returns), or is it the duopoly created by Fresenius and DaVita using loopholes and exploiting private insurance?

 

I'm still trying to fully understand the moat and what would cause it to be lost.

 

It is a commoditized business in the sense that the treatment and the price they charge is standardized, but that is true for a lot of other medical treatments too.

 

They definitely need to operate with RN’s on the floor at all times and a doctor needs to be on call. as mentioned above, the quality of care is very important, most patients are very sick and their blood pressure and medication (Heparin, EPO etc) needs to be managed. Nurses need to be trained on the machines and the treatment and patients management and the work is quite intense as stated above, which in conjunction with the moderate pay results in considerable turnover. Mistakes on the floor can easily result in death of a patient.

This is certainly not a business that every idiot can run. FWIW, I don’t like the CEO and I think he has outlived his usefulnes, but he regards DVA as his baby (somewhat justifiable so).

 

Can you elaborate on your feelings about Thiry?

[MrB]

I read some online stories by nurses who do dialysis. It's not that easy. New nurses make mistakes and some incidents are fatal. They need to well trained and guided by senior nurse. The work is very intense compared to working in the hospital, resulting shortage of workers. Also, nurses need special educations and pass tests, etc.. Anyway, my point is this is not a commodity business.

 

Maybe the issue here is DVA 's margin is capped. Its clients will never allow it to make excessive profits, nor will they want DVA lose incentives to open new centers. So DVA is like a regulated utility. But even with limited margin upside, current valuation is heavily discounted.

 

I understand what you're saying.  But are these training/testing requirements that allow for a high barrier to entry (and high returns), or is it the duopoly created by Fresenius and DaVita using loopholes and exploiting private insurance?

 

I'm still trying to fully understand the moat and what would cause it to be lost.

 

It is a commoditized business in the sense that the treatment and the price they charge is standardized, but that is true for a lot of other medical treatments too.

 

They definitely need to operate with RN’s on the floor at all times and a doctor needs to be on call. as mentioned above, the quality of care is very important, most patients are very sick and their blood pressure and medication (Heparin, EPO etc) needs to be managed. Nurses need to be trained on the machines and the treatment and patients management and the work is quite intense as stated above, which in conjunction with the moderate pay results in considerable turnover. Mistakes on the floor can easily result in death of a patient.

This is certainly not a business that every idiot can run. FWIW, I don’t like the CEO and I think he has outlived his usefulnes, but he regards DVA as his baby (somewhat justifiable so).

 

Can you elaborate on your feelings about Thiry?

Can you two take that part of the discussion offline please?  I hate to listen to a man's "bleeding heart" ;D

[Jurgis]

Can you two take that part of the discussion offline please?

 

Can you not take that part of the discussion offline please.  8)

[rb]

Can you two take that part of the discussion offline please?

 

Can you not take that part of the discussion offline please.  8)

LOL! You want hear more about Citizen D'Artagnan?  ;D

[DooDiligence]

I read some online stories by nurses who do dialysis. It's not that easy. New nurses make mistakes and some incidents are fatal. They need to well trained and guided by senior nurse. The work is very intense compared to working in the hospital, resulting shortage of workers. Also, nurses need special educations and pass tests, etc.. Anyway, my point is this is not a commodity business.

 

Maybe the issue here is DVA 's margin is capped. Its clients will never allow it to make excessive profits, nor will they want DVA lose incentives to open new centers. So DVA is like a regulated utility. But even with limited margin upside, current valuation is heavily discounted.

DaVita IS a commodity business. The reasons you've listed don't invalidate that. It doesn't matter how hard the work is. Let me give an example. Oil is a commodity business and Coke is not. But making oil is hard. I can't just go out there and produce oil. The work is very intense and you need lots of very expensive equipment and highly trained people. I can however make Coke. The process is easy and doesn't require much in terms of capital. These things don't change the commodity/not commodity aspect.

 

In the case of dialysis the equipment is commercially available, there are lots of nurses already trained and you can create/train more nurses. Yes it would take some time, but there are no barriers to making nurses. There is nothing proprietary here.

 

One thing that dialysis centres have is a sort of first mover advantage. It's hard to travel for dialysis so patients choose the centre closest to their home. On top of that there's not enough people with ESRD. So if you open another centre in an area that has an existing one I suspect that capacity utilization would drop so much as to make both centres unprofitable. That's typical of a commodity business and not really a moat.

 

Very sharp, thanks for unpacking this!

[Read the Footnotes]

Can you two take that part of the discussion offline please?

 

Can you not take that part of the discussion offline please.  8)

 

Years ago Kent Thiry was very well respected. If there is a well reasoned and respectful argument why he did not or does not deserve that respect, I would be very interested in hearing it.

 

I haven't been following DaVita closely for updates, so I would be very interested in hearing what if anything has changed.

[Read the Footnotes]

I read some online stories by nurses who do dialysis. It's not that easy. New nurses make mistakes and some incidents are fatal. They need to well trained and guided by senior nurse. The work is very intense compared to working in the hospital, resulting shortage of workers. Also, nurses need special educations and pass tests, etc.. Anyway, my point is this is not a commodity business.

 

Maybe the issue here is DVA 's margin is capped. Its clients will never allow it to make excessive profits, nor will they want DVA lose incentives to open new centers. So DVA is like a regulated utility. But even with limited margin upside, current valuation is heavily discounted.

 

I understand what you're saying.  But are these training/testing requirements that allow for a high barrier to entry (and high returns), or is it the duopoly created by Fresenius and DaVita using loopholes and exploiting private insurance?

 

I'm still trying to fully understand the moat and what would cause it to be lost.

 

It is a commoditized business in the sense that the treatment and the price they charge is standardized, but that is true for a lot of other medical treatments too.

 

They definitely need to operate with RN’s on the floor at all times and a doctor needs to be on call. as mentioned above, the quality of care is very important, most patients are very sick and their blood pressure and medication (Heparin, EPO etc) needs to be managed. Nurses need to be trained on the machines and the treatment and patients management and the work is quite intense as stated above, which in conjunction with the moderate pay results in considerable turnover. Mistakes on the floor can easily result in death of a patient.

This is certainly not a business that every idiot can run. FWIW, I don’t like the CEO and I think he has outlived his usefulnes, but he regards DVA as his baby (somewhat justifiable so).

 

I'm actually not bullish on DaVita, but . . .

 

If this is a commodity, how do you explain the oligopoly or duopoly then? Duopoly typically does not develop or endure in commodity businesses with no moats.

 

Do you believe there is the potential for economies of scale in this business?

What about the fact that high volume centers tend to produces better medical outcomes in most treatment areas?

[Guest roark33]

I read some online stories by nurses who do dialysis. It's not that easy. New nurses make mistakes and some incidents are fatal. They need to well trained and guided by senior nurse. The work is very intense compared to working in the hospital, resulting shortage of workers. Also, nurses need special educations and pass tests, etc.. Anyway, my point is this is not a commodity business.

 

Maybe the issue here is DVA 's margin is capped. Its clients will never allow it to make excessive profits, nor will they want DVA lose incentives to open new centers. So DVA is like a regulated utility. But even with limited margin upside, current valuation is heavily discounted.

 

I understand what you're saying.  But are these training/testing requirements that allow for a high barrier to entry (and high returns), or is it the duopoly created by Fresenius and DaVita using loopholes and exploiting private insurance?

 

I'm still trying to fully understand the moat and what would cause it to be lost.

 

Surely if one considers DVA/FSN to be "exploiting private insurance" one cannot simply gloss over the fact that they are not allowed to make money on 90% of their patients? DVA's revenue per treatment from government increased by 0.3% per annum over the last 10 years. Consider inflation and see the attached chart to get an idea of how long this has been going on. Virtually no other healthcare providers have been going without meaningful basket adjustments for so long.

Now for another exception. How come insurers can kick back patients to government after 30 months? It was set 12 months in the 1981, 18 months in 1990 and 30 months in 1997 and it came very close to being set at 42 months in 2007 (Bush vetoed it). Surely it is time for the commercial guys to step up too, because the last time they did was in 2007! However, the question is how valuable is the 30 months? The more I look into it the more I realise it is a significant number. So at the moment after 2.5 years the patient goes to government, right. Mortality rates are often quoted at around 20% which is also the number that sits behind the frequent statement of dialysis patients living 5 years. However when you look at the actual data from USRDS.ORG you note that 16% of your ESRD population is over 75 years old plus another 23% 65-74 old and the survival rate of those are naturally low. Only 8.3% and 1.9% respectively will live 10 years and longer, which tells you the majority of the often sited 20% mortality number is made up of 65 years and older patients. However survival of 10 years and longer jumps to 27% for 45-64 year old, 54% for 22-44 year old and 75% for your 0-21 year old. These last three age groups make up the 61% of your ESRD population and what you realise is that the ability to kick back these patients to government after 2.5 years is extremely valuable to private insurers. Just basic insurance logic tells you the biggest asset is a young healthy patient versus your biggest liability of a young sick patient especially if they have what looks to me to be the most expensive chronic disease in the system. BUT WHY is private afforded this extremely favourable financial treatment? From my understanding this is really the only disease where commercial is allowed to do this.

 

 

 

---

 

One part of this analysis that doesn't get as much focus is the lobbying power of the insurance companies.  The main reason I don't own DVA right now, despite being ok with the payor relationship is I think the insurance companies have now decided that they are strong enough to push back against the AFK, and are fine with DVA's threat to go after the 30 month rule.  The insurance companies are large enough now that they will lobby to keep a lid on that limit.  DVA is a small fish and the insurance companies have decided to circle the wagons on this issue.  My two cents.

 

[Jurgis]

Can you two take that part of the discussion offline please?

 

Can you not take that part of the discussion offline please.  8)

LOL! You want hear more about Citizen D'Artagnan?  ;D

 

Did they release "Twenty Years After"?  8)

 

 

[MrB]

---

 

One part of this analysis that doesn't get as much focus is the lobbying power of the insurance companies.  The main reason I don't own DVA right now, despite being ok with the payor relationship is I think the insurance companies have now decided that they are strong enough to push back against the AFK, and are fine with DVA's threat to go after the 30 month rule.  The insurance companies are large enough now that they will lobby to keep a lid on that limit.  DVA is a small fish and the insurance companies have decided to circle the wagons on this issue.  My two cents.

I think the lobbying is a big part of the story and also an important factor in the research process, because just about every piece of research, study, opinion piece, complaint, legal opinion, you name it seem to have some lobbying behind it. For Davita "Kidney Care Partners" seems to be the main one. http://kidneycarepartners.com/kcp-partners/ Hell, I struggle to keep my own bias in check.

 

Having said that lobbying has been a big part of the story since the birth of the industry in 1971 (see expert to follow for a rather unorthodox example!). Also I think one has to ask why DVA/FSN have been able to establish an oligopoly in the presence of significant lobbying power of other industry players, including the private insurers. In my mind the latter always had significant power.

 

Not to discount your point about the private insurers' power, it's a valid point. However, the issue around the AKF is not so simple. It has precedent and operate under "legal cover" from shortly after the the changes brought about in 1996 as mentioned earlier in the thread. This fight is not new and any sudden changes in policies around the AKF will cause significant disruption to a big part of the patient population. Lastly the very fact that the only real beneficiary in disrupting the AKF model is the insurance industry counts against it especially since the argument from the patient side is that these are "efforts by certain health insurers to discriminate against individuals with ESRD" as you can see from this (biased) letter

http://kidneycarepartners.com/wp-content/uploads/2014/10/Patient-Protection-and-Affordable-Care-Act-HHS-NBPP-for-2018-October-6.pdf

 

Not saying it cannot happen-just that I'm thinking its easier said than done! Again, it's complicated...hence the moat?

 

Taken from "Origins of the Medicare Kidney Disease Entitlement: The Social Security Amendments of 1972"

https://www.ncbi.nlm.nih.gov/books/NBK234191/

"Glazer, at a New York NAPH press conference on November 3, the day before the

hearing, had announced his intention to undergo dialysis before Chairman Mills

and the Ways and Means Committee. The National Kidney Foundation opposed

the effort—directly in discussions with Glazer and indirectly through Eli

Friedman, advisor to NAPH. Schreiner and Plante had been lobbying Congress

assiduously, seeking support for kidney treatment programs from all sources—

the tax committees, the health legislative committees, and the appropriations

committees. They feared that an accident would cancel all the progress they had

made, and Schreiner stressed this possibility when he tried to dissuade Glazer

from dialyzing before the committee. Given these activities, Schreiner's incredulity

was all the greater when he received a telephone call at home on the evening

before the hearing. Glazer had arrived in Washington, D.C., from New York, and

was calling to ask Schreiner if a Georgetown University dialysis machine could be

brought to the hearing room the next morning for use at that time (Institute of

Medicine, 1989). Schreiner, suppressing his anger, trucked a machine over to the

Longworth House Office Building on Capital Hill. Barred from attending the hearing by the National Kidney Foundation, which did not wish him to lend its prestige to the event, he sent a Georgetown nephrology fellow, James Carey, to act as attending physician....

 

 

 

[sleepydragon]

Can you two take that part of the discussion offline please?

 

Can you not take that part of the discussion offline please.  8)

 

Years ago he was very well respected. If there is a well reasoned and respectful argument why he did not or does not deserve that respect, I would be very interested in hearing it.

 

I haven't been following DaVita closely for updates, so I would be very interested in hearing what if anything has changed.

 

Who is the "he" you are referring to? Thanks!