Explore

Patient Care     |     Business     |     Health Policy     |     Eclectic     |     Credits

Texas Monthly

The Dialysis Dilemma

Undocumented immigrants usually don’t qualify for treatment for kidney disease—until it becomes life-threatening and much more expensive. (2018)

(Direct link to article here.)

 

By Charlotte Huff

The dialysis machines hum with a chronic, low-level sound, the final bulwark against kidneys that can no longer filter excess fluids and toxins from the body. Some patients doze under muted lights, covered by blankets. Others watch TVs attached to long, retractable arms that hang over each reclining chair. Without these regular treatments to cleanse the blood, fluids build up, swelling the body and settling into the lungs, making it hard to breathe. Potassium accumulates in the bloodstream, straining the heart, risking an abnormal and potentially fatal heart rhythm. After four hours, these 22 patients leave. The equipment and the chairs are sterilized for the next shift. Four shifts run Monday through Saturday, the staff prepping for the first wave before 5 a.m. Some twenty hours later, shortly after 1 a.m., the final group will be disconnected from the machines and sent home.

Despite the wearying, thrice-weekly regimen, these roughly 160 patients—most of whom are undocumented—are the lucky ones; they get regular rather than emergency-only dialysis. Riverside Dialysis Center, which opened in 2008 and is operated by Houston’s Harris Health System, doesn’t have the room to squeeze in any more patients.

The unlucky ones must frequently wait until their condition qualifies them for what is essentially crisis dialysis. That means that they’re evaluated when feeling unwell—often returning to the emergency room again and again—until their potassium levels and other symptoms become sufficiently life-threatening and they are administered the needed dialysis.

Undocumented immigrants end up in this situation because they don’t qualify for coverage through Medicare, traditional Medicaid, or other public insurance options. But federal law requires hospitals to stabilize all patients in a medical crisis or transfer them to a facility that can stabilize them. At that point, emergency Medicaid might pick up part of the tab. But the bill can be much heftier by then. If patients are sick enough to need a hospital bed, their care averages nearly $14,000 per visit versus about $1,000 for emergency dialysis administered on an outpatient basis, according to recent Harris Health data.

Thus, an expensive dilemma persists. Immigrants living with kidney failure suffer until doctors decide that they’re in bad enough shape to require emergency treatment. And taxpayers pay much more than we would if we were able to help people before they’re in crisis.

“It’s very tough to come in and tell someone who is really short of breath and really sick, ‘We just don’t have space to treat you today; come back tomorrow,’ ” says Rajeev Raghavan, a kidney specialist at Houston’s Baylor College of Medicine who also practices at Ben Taub Hospital, which is part of Harris Health System. “And if they do come back sicker, they’re going to be here in the hospital for days, when it could have just been a short [dialysis] treatment for that day.”

Over the past decade, starting with a research project during his nephrology training at Baylor College of Medicine, Raghavan has become part of a national cadre of physicians and researchers who argue that delaying dialysis until someone is at death’s door is inhumane and wastes money.

“Rajeev has really become an organizer of physicians around this issue—he’s published one article after another,” says Nancy Berlinger, a research scholar who co-directs the Undocumented Patients project at the Hastings Center, a bioethics research institute in Garrison, New York. For doctors and other clinicians, she says, “treating patients using emergency-only provisions is a case where moral distress is being produced every single week. They can see very starkly that they are providing a much lower standard of care compared to scheduled dialysis.”

Yet by highlighting these patients’ plight, the 39-year-old Raghavan has strayed into one of the nation’s most contentious political issues: what our medical system owes to people who are in this country illegally. Many doctors, such as Raghavan, believe that all ill human beings deserve the same treatment, regardless of legal status, including the estimated 6,500 undocumented immigrants with kidney failure living in the United States. Immigration hard-liners, by contrast, argue that providing medical care only encourages and rewards those who have broken laws to be here.

The result is a paradox that complicates both the immigration and the medical debates: scant public money is spent on preventive care for undocumented immigrants, yet federal law requires hospitals to treat any patient whose life may be in peril.

As a matter of medicine, Raghavan and his allies have made a strong case by compiling data and publishing studies about the disastrous results of forcing immigrants to rely only on emergency care. Undocumented immigrants who rely on emergency dialysis to survive are in the hospital nearly ten times as long as those who get regular dialysis treatment, according to a study that Raghavan was involved with. They are also fourteen times as likely to die. 

By the time patients reach the crisis dialysis stage, the suffering is often terrible. Edlyn Bustamante, a registered dietitian in Ben Taub’s dialysis unit who is frequently called upon to translate for Spanish-speaking patients, describes patients who are breathing rapidly, and with shallow breaths, almost as if they’re experiencing a panic attack. Their feet have often become so swollen that they resemble elephant feet. “It’s heartbreaking when they tell me, ‘I’ve been coming every week, and they send me away,’ ” she says.

Some desperate patients resort to subterfuge to qualify for emergency treatment. Hilda Ruiz, an immigrant from Honduras who is in the United States under the Deferred Action for Childhood Arrivals program, now gets regular dialysis because she became the beneficiary of a special fund for patients like her. But she vividly recalls the days she would eat a banana or drink some orange juice, both rich in potassium, on the way to fellow Harris Health hospital LBJ, trying to drive up her potassium levels enough to meet emergency criteria. Even though she knew that pushing her potassium up too high could trigger a fatal heart rhythm, she felt the risk was worth it.

Scariest was the struggle to breathe, says the 31-year-old Houston resident, sitting in her kitchen as her young nephew runs in and out of the room. A few times, nurses helped her out on the sly. “Sometimes they give me a little bit of orange juice so my potassium can go a little bit up, so they can do dialysis because I was feeling so bad,” Ruiz says.

At Ben Taub and LBJ, the steady influx of kidney failure patients has resulted in delayed medical care for others in the emergency room. Dialysis patients require heart testing, blood work, and other costly, time-consuming medical screenings to determine if they meet emergency criteria. That eats into time that clinicians can spend on other patients, says Nathan Deal, an emergency physician and administrator at Ben Taub.

How much does all this extra care cost? One study, involving a small group of undocumented patients at Harris Health, found that emergency-only dialysis costs nearly four times as much annually as dialysis sessions three times a week: $285,000 versus $77,000. Emergency Medicaid might pay a fraction of that $285,000, but the hospital will be stuck with what the patient cannot pay. 

The doctors at Harris Health have practiced in the crosshairs of this dialysis dilemma for some two decades, as construction and other jobs have attracted immigrants to the booming city. John Foringer, the chief of medicine at LBJ Hospital and a kidney specialist, recalls that only about twenty patients overall required emergency dialysis when he was completing his physician training nearly a generation ago. Now he estimates that the patient load at Harris Health averages about four hundred at any given time.

Despite questions otherwise, Foringer says he doubts immigrants move to Houston solely for dialysis. “Many of them, I believe, had no idea that they had kidney disease to the degree that they did, because they were really not receiving health care in their home country.”

After kidney problems have been identified, doctors must monitor patients and wait until they become sick enough to treat. Asked if he could think of a similar medical scenario, in which doctors delay until a patient’s condition becomes life-threatening before intervening, Foringer’s response is firm: “No. This is a unique situation.”

Outside of the routine dialysis provided for the lucky patients at Riverside, most undocumented patients in Texas get emergency-only care. One exception is San Antonio’s University Health System. A spokesperson there confirmed that uninsured patients, including undocumented individuals, get routine dialysis with the help of an American Kidney Fund assistance program that pays their insurance premiums. That program has also helped some Harris Health patients, including Ruiz. And at least one insurer in Texas writes policies for undocumented immigrants.

King Hillier, a Harris Health executive, said that as the Harris Health dialysis situation has intensified in recent years, he has researched strategies implemented elsewhere. Hillier, the vice president of public policy, government relations, and corporate communications at Harris Health, learned that several states, such as New York and North Carolina, have modified the statutory language for who qualifies for emergency Medicaid so that routine dialysis can be covered for immigrants who haven’t shown proof of legal status. He’s been talking to officials at other safety-net hospitals, including Parkland, in Dallas, about making a similar proposal to state officials. “If you can avoid the hospitalization, you have saved the state money,” he says.

While the Medicaid eligibility rules are a bit complex, such a change would likely open up routine dialysis to the majority of undocumented immigrants with kidney failure living at or near the poverty line, says Anne Dunkelberg, who oversees health care policy for the Austin-based Center for Public Policy Priorities.

Success would require some heavy lifting in the current anti-immigration environment, Dunkelberg says. She notes that federal officials would have to sign off on any changes to emergency Medicaid language. Still, she thinks a focus on the bottom line might sway some state legislators, but it’s hard to predict with lawmakers. “I would not want to have to vote against lifesaving treatment that also saves money,” she says. “I don’t think I could handicap how that will come out.”

In the meantime, Harris Health launched a new program last year to train some emergency patients to self-administer dialysis at home in a process called peritoneal dialysis. The patient learns how to deliver the dialysis solution through a tube into the lining around the abdomen—called the peritoneum—in order to shed toxins and extra fluids. The approach requires at least twenty hours to train the patient after a catheter is surgically implanted into the patient’s abdomen.

By June, at least eleven Harris Health patients had been trained, including a man who asked that he be identified only as Javier. The 46-year-old, who is undocumented and uninsured, was diagnosed with kidney failure at Harris Health, says Jose Perez, a kidney specialist and Riverside’s medical director. He needed dialysis but wasn’t quite sick enough to meet emergency criteria. The fluids kept building up, and the medications weren’t helping much, according to Perez. “He looked like a balloon. He was just so full of fluid.”

Soon after Javier started at-home dialysis in January, his energy levels increased and his ability to walk improved as his body shed the excess fluids. By May, he weighed in at the Riverside clinic at 145 pounds, 50 pounds lighter than when he started.

It’s a promising option for some patients, and one that Harris Health officials want to expand upon by adding more space for patient training. But it’s only a piecemeal solution, Raghavan says. The only way to bring relief to all patients and overstressed medical institutions alike is by getting more people insured, he says.

Raghavan was part of a recent research study that powerfully demonstrated this point. The study followed 32 undocumented Harris Health patients who were able to get insurance with the help of the American Kidney Fund premium assistance. When they did so, their collective total number of emergency visits plummeted, from 596 during the three months prior to coverage to just 5 over the subsequent three months. The total number of days in the hospital was similarly slashed, from 101 to 19. 

To Raghavan, this is evidence that taxpayers are taking a financial hit for crisis dialysis, regardless of their personal beliefs about undocumented immigrants. “It’s dollars-and-cents,” he says. “We’re spending more money to take care of them, with poor-quality care.”