Dialysis clinics are stalled while awaiting certification

A surge of 700 new Hawaii kidney dialysis patients a year is driving an increase in treatment facilities statewide.

The state’s two dialysis operators, Liberty Dialysis and U.S. Renal Care, are planning to open as many as half a dozen new clinics annually over the next five years.

Building the new clinics will help meet the increased demand, but not until the facilities are certified by the state Department of Health and federal authorities, a process that can take up to three years.

Without certification, the dialysis clinics can’t get reimbursed for treating Medicare and Medicaid patients, which comprise as much as 85 percent of the dialysis population.

“Because we have 168,000 Hawaii residents with chronic kidney disease and every year Hawaii has 700 more dialysis patients … we have an urgency,” said state Rep. John Mizuno (D, Kalihi Valley), chairman of the House Health and Human Serv­ices Committee. “In Hawaii, we have such a high rate per capita of chronic kidney disease. There’s a great need to open dialysis clinics. The word is unconscionable.”

The number of Hawaii patients who need kidney dialysis, a lifesaving treatment that filters waste, excess fluid and toxins from the blood of patients with failing kidneys, grew to nearly 4,000 from roughly 3,300 in 2014 and 2,300 in 2006, according to the Western Pacific Renal Network. Diabetes and high blood pressure are the cause of kidney failure in more than 80 percent of people in Hawaii afflicted with the condition.

The delays are causing patients covered by Medicare, the government health insurance program for seniors, and Medicaid, for low-income residents, to instead get treatments at emergency rooms, which cost three to four times more than a dialysis clinic, Mizuno said.

“New clinics with new equipment needlessly stand idle, not being able to serve thousands of dialysis patients in Hawaii, while patients scurry to clinics located many miles away from their homes, sometimes from opposite sides of the island,” Mizuno said in a statement last week to mark the opening of a new Liberty Dialysis center in Mililani. “The state must expedite the review and certification process to ensure our people are able to secure their lifesaving dialysis treatments.” Mizuno is considering legislation to expedite approvals for dialysis clinics.

At least three times a week, Nestor Marcos endures four hours of dialysis treatment in Waipahu before driving 20 miles home to Waialua after midnight. The 63-year-old diabetic, whose treatment runs from about 8:15 p.m. to 12:30 a.m., the only open hours available at the dialysis clinic, says the procedure drains his body and makes it hard for him to get home safely.

“Afterwards I’m tired. I feel weak. The worst part is I have to drive at night,” said Marcos, who has been on dialysis since June. Many dialysis units are at capacity on Oahu, so new patients are often treated after normal hours. “It’s hard because nobody can drop me off and pick me up. I get home at about 1:30 a.m. It’s dangerous. Right now, no more choice.”

The DOH has blamed certification delays on a lack of resources.

“The Department of Health recognizes the importance of timely certification and inspection services for all health care facilities in the state and we are working with CMS (the U.S. Centers for Medicare and Medicaid Services) on both short- and long-term strategies to reduce delays in the certification process,” said DOH spokeswoman Janice Okubo. “Improving our licensing program to deal with this and other issues in a more efficient and timely manner is definitely one of our top priorities.”

The projected opening of as many as half a dozen facilities annually over the next five years means there will likely be more backlogs in the system, said Steve Nottingham, general manager of Liberty Dialysis.

“When we have to build it and get it certified, it’s taken three to five years between the time we demonstrate there’s a need and the time we can service the first patient,” Nottingham said. “Hawaii has a growing population that needs access to care. The system creates obstacles that slows down access to care. It drives patients to have dialysis treatments at times that are not ideal for them.”

The situation was so urgent for dialysis centers last year that the DOH spent $140,000 to contract half a dozen Arizona inspectors to complete delayed certifications for 11 dialysis centers.

“As demand for dialysis care continues to grow, more and more patients face challenges to receive treatment,” said Pliny Arenas, vice president of operations for U.S. Renal Care’s Hawaii region. “Many are forced to drive long distances late at night, and those that can’t make it often end up being admitted to local hospitals.”

The state has more than 30 dialysis clinics, four of which are still awaiting certification.

While Liberty Dialysis opened Thursday in Mililani, the clinic is not yet certified to take patients. Two others recently built in Salt Lake and Ala Moana treat only private-pay patients as the company awaits certification to treat Medicare and Medicaid recipients. Another facility, operated by U.S. Renal, is also awaiting certification.

The significant growth in chronic kidney disease isn’t slowing down.

One in 7 people have kidney disease, with Native Hawaiians, Pacific Islanders and Asians genetically more susceptible to the illness.

The number of dialysis patients in the United States is growing on average about 4 percent annually. In Hawaii the growth is between 6 and 8 percent, according to Liberty Dialysis, which has invested about $100 million in facilities statewide over the past 15 years, with an average cost of $4 million to $5 million per facility.

The company plans to invest another $20 million to $30 million in additional clinics over the next five years. U.S. Renal also plans to expand but didn’t disclose details.

The average patient costs the health care system an estimated $80,000 to $100,000 per year, which includes dialysis treatments, doctor visits, hospitalizations and drugs.

“What will make the biggest impact in Hawaii to slow down and prevent end-stage renal disease has mostly to do with keeping blood sugar and blood pressure normal,” said Dr. James Ireland, a Liberty Dialysis partner and medical director. “We need to eat better and exercise more.”