[Congressional Record Volume 143, Number 157 (Sunday, November 9, 1997)]
[Extensions of Remarks]
[Page E2282]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




   ROUGH DRAFT OF LEGISLATION TO IMPROVE QUALITY OF CARE IN NATION'S 
                            DIALYSIS CENTERS

                                 ______
                                 

                        HON. FORTNEY PETE STARK

                             of california

                    in the house of representatives

                       Saturday, November 8, 1997

  Mr. STARK. Mr. Speaker, I am today including in the Congressional 
Record the rough draft of a bill which represents several years of hard 
work within the kidney disease community on how to improve the quality 
of care for our Nation's nearly 250,000 kidney disease patients.
  I am asking that the bill be printed in the Record in the closing 
hours of this session of the 105th Congress, so that interested parties 
can study the proposal over the next several months and offer 
suggestions and changes. I will be working on the bill over the coming 
months to develop a consensus on this effort to improve the quality of 
life of the Nation's kidney disease patients, and I hope to introduce 
it formally, with appropriate changes, when the second session meets in 
January.
  Basically, the draft bill would create a continuous quality 
improvement [CQI] program that requires all providers treating end-
stage renal disease patients under Medicare to provide data on the 
outcomes and quality of life of their patients, and to seek to improve 
that quality.
  Those who achieve outstanding quality outcomes will be recognized for 
their special contributions. Those who fail to meet agreed-upon quality 
standards will be counseled and worked with to improve. Patients in 
most communities where there is more than one dialysis provider will be 
empowered to switch to centers which provide the better outcomes and 
quality. All the care givers, including the doctors, will be part of 
the new effort of measurement and improvement.
  The result should be improved mortality and morbidity rates, improved 
energy levels, improved rates of return to work, and of 
transplantation.
  Mr. Speaker, for over 23 years Medicare has been paying for the 
catastrophic expenses of treating end-stage renal disease, through 
three times a week life-giving dialysis, through transplantation, and 
through all the extra hospitalizations, tests, and pharmaceuticals 
needed by these citizens. The cost per patient per year is, counting 
everything, estimated between $50,000 and $60,000.
  The program has been a tremendous success. It has saved enormous 
numbers of lives and in many cases provided a good quality of life for 
decades in which people have continued to contribute to their 
communities and loved ones.
  Yet, after 23 years experience, we can and should do better. There 
are enormous differences between dialysis centers. After adjusting for 
every imaginable factor, scholars continue to find that some dialysis 
centers have death rates much higher than the average. To be blunt, 
some dialysis centers should be avoided as dangerous to one's health. 
Some dialysis centers seldom or never refer patients--on whom they make 
some money--to transplantation so that they will never again need 
dialysis. Some centers' patients spend many more days per year in the 
hospital than the ``best practice'' centers. Some centers are able to 
get their patients back to work; in others, a lifetime of disability 
and welfare becomes the norm. And as the GAO reported to Congress on 
September 26, the number of appropriate lab tests given to ESRD 
patients vary enormously among centers, raising questions of quality 
and of fraud and abuse.
  With Medicare--not total--expenditures on ESRD patients likely to be 
about $9 billion in the coming year, we need to do better. We need to 
reduce the hospitalization rates and the unexplained death rates. We 
need to increase the opportunities for transplantation and for the 
return to work and a full range of normal activities. The draft bill 
would--I believe--help patients and providers work together to achieve 
these goals.
  Finally, managed care has become a fact of life for most Americans, 
but most ESRD patients are not in managed care. Indeed, currently there 
is a prohibition on patients who reach ESRD status joining a managed 
care plan--although a person already in a managed care plan who reaches 
ESRD can stay in his or her plan. The fear has been that a managed care 
company could so cut access to services and quality care for these very 
vulnerable patients that it could lead to greatly increased patient 
death and illness. Until we have strong quality standards in place and 
know how to measure ESRD outcomes, it is dangerous to place these 
patients in systems designed to reduce utilization. The CQI legislation 
I am introducing will help ensure that for those few ESRD patients in 
managed care, there is a guarantee of quality. The lessons learned from 
this legislation will help permit the day when we could confidently 
entrust this population to disease management programs.
  I want to thank all of the rental and patient associations who have 
been working with HCFA to improve quality and who have been offering 
suggestions for CQI legislation. In particular, I want to thank the 
Renal Physicians Association. This draft legislation builds on many of 
the ideas that are already underway in the renal community and at HCFA, 
and I believe it is a bill that can achieve consensus support 
throughout the renal community.
  To repeat, I welcome additional suggestions and refinements to this 
proposal--and hope it is legislation that we can move forward in 1998.

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