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Dialysis care is in the hands of California voters for the third time in four years

While proponents of Proposition 29 say it is intended to protect dialysis patients, experts share concerns over its potential effects.

Adrian Perez, wearing a black shirt and white cap, sits in a chair with a laptop in his lap while receiving dialysis in his right arm. A blue blood pressure band is around his right arm.

Adrian Perez undergoes dialysis at a DaVita Kidney Care clinic in Sacramento, Calif., on Monday, Sept. 24, 2018. Will the third time be the charm for a 2022 California ballot measure its supporters say will improve the quality of care at kidney dialysis clinics? Proposition 29 would require a doctor, nurse practitioner or physicians' assistant to be present during treatment at the state's 600 outpatient dialysis facilities. (AP Photo/Rich Pedroncelli, File)

By Maya Gomes

For the third election in a row, California voters will decide on regulations for dialysis centers November 8 in Proposition 29.

Prop. 29 would require dialysis centers to have a physician, nurse practitioner, or physician assistant with at least six months of relevant experience on-site or available via telehealth.

However, there hasn’t been any proof that increased staffing will improve patient care at dialysis centers, said Erin Duffy, a research scientist at the USC Schaeffer Center for Health Policy and Economics.

“There haven’t been studies that link improved quality with that kind of staffing,” Duffy said. “Typically, before you would want to do some sort of sweeping change in the way staffing structures would happen, you would want it to be evidence based.”

Among other things, the proposition also requires clinics to disclose infection data to the state, publish a list of physicians with 5% or more ownership in practices and protect clinics from a reduction or closure of services without approval from the state.

According to the L.A. Times, however, clinics are already required to have a physician on staff overseeing patients’ care and a kidney specialist directing patients’ treatment plans.

“I think that overall there is the potential for harm, particularly in underserved areas where small facilities are and would be at risk for closing,” said Dr. Eugene Lin, an assistant professor of Medicine and Health Policy & Management at USC’s Keck School of Medicine and the Price School of Public Policy.

USC Keck partners with DaVita to run a dialysis unit through the USC Kidney Center, located by Keck Hospital in the Ramona Gardens area. Lin claims no affiliation with the partnership.

An on-site doctor “would not have the authority to make changes to the care prescribed by a patient’s doctor,” the L.A. Times argues in their editorial condemnation of the bill. This makes the requirement a redundancy that could cost clinics several hundreds of thousands of dollars annually, potentially forcing them to scale back operations or close entirely, according to the L.A. Times. Additionally, dialysis centers are already required to report their infection data to the federal government.

Prop 29. is the third attempt to regulate the dialysis industry in the past four years: Prop. 8 in 2018 proposed similar changes to the industry, as did Prop. 23 in 2020. Both previous propositions were shut down by approximately 60% of voters.

“I’m not aware that much has changed in the last two years,” Duffy said. “[There is] no new data that has been presented that I’ve seen on why this is needed. And so it’s hard for me to see the outcome being very different from two years ago.”

All three propositions were sponsored by the Service Employees International Union-United Healthcare West, who has been in a drawn-out battle with private dialysis companies DaVita and Fresenius to unionize workers. DaVita and Fresenius have combined ownership or operation of 75% of the 650 dialysis facilities in California, which treats about 80,000 California residents, according to state analysts’ estimates.

“The policies in general have not been advantageous from a patient perspective,” Lin said. “It’s clear that it is not benefiting patients at all because it’s sort of putting them in the crosshairs of what looks to be like a labor dispute.”

The proposition, which is being promoted by the union as a measure to protect patients receiving dialysis care from exploitation, is opposed by several prominent healthcare groups, including the California Medical Association, the California chapter of the American Nurses Association and the American Academy of Nephrology PAs, along with the Renal Physicians Association, the California Dialysis Council and others.

Lin also expressed concerns over healthcare policy being decided by state voters who may not be educated on the intricacies of the dialysis industry.

“It does strike me as something where we should be concerned about overly regulating a highly complicated and technical industry via ballot pressure,” Lin said. “Instead what we should be doing is allow health care experts and policy experts to be regulating it, perhaps at a federal level.”