Originally Posted at: http://www.latimes.com/news/local/la-me-kaiser3may03,0,7877009.story?track=tottext
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Kaiser Put
Kidney Patients at
Risk
By opening its own transplant center in
the Bay Area, the HMO harmed recipients' odds of obtaining organs, a
Times probe finds.
By Charles Ornstein and Tracy Weber,
Times Staff Writers
May 3, 2006
In
mid-2004, more than 1,500
Kaiser Permanente
patients awaiting kidney transplants in Northern California got form
letters that forced them to change the course of their treatment.
Kaiser would
no longer pay for transplants at outside hospitals, even
established programs with thousands of successes. Instead, adult
patients would be transferred to a new transplant center run by Kaiser
itself — the first ever opened by the nation's largest HMO.
Within
months after Kaiser's kidney program in San Francisco started
up, its waiting list ranked among the longest in the country. No other
center had ever put together such a list so fast.
The patients
didn't know it, but their odds of getting a kidney had
plummeted.
Kaiser's
massive rollout in Northern California endangered patients,
forcing them into a fledgling program unprepared to handle the
caseload, according to a Times investigation based on statistical
analyses, confidential documents and dozens of interviews.
Hundreds of
patients were stuck in transplant limbo for months because
Kaiser failed to properly handle paperwork. Meanwhile, doctors
attempting to build a record of success shied away from riskier organs
and patients, slowing the rate of transplants performed.
National
transplant regulators apparently did not notice the program's
failures, though some were obvious in the statistics the regulators
themselves posted on the Internet.
In 2005, the
program's first full year, Kaiser performed only 56
transplants, while twice that many people on the waiting list died,
according to a Times analysis of national transplant statistics.
At
transplant centers statewide, the pattern was the reverse: More than
twice as many people received kidneys than died.
Kaiser also
suffered by comparison to the two outside hospitals that
previously had tended to its Northern California patients. In each of
the two years before Kaiser opened its program, UC San Francisco and UC
Davis medical centers together performed at least 168 transplants on
Kaiser patients, three times as many as Kaiser managed in its first
full year.
"If they
couldn't handle as many as they were doing before, they should
have just transferred some" patients, said Neva Smith, whose daughter,
Alison Bertino, was moved to Kaiser from UC San Francisco.
Bertino, 30,
died last June while waiting for a kidney.
It is
difficult to say whether she or any other Kaiser patients died as
a direct result of the program's faltering start. What is clear is that
many fewer patients received transplants than before, forcing them to
remain on grueling sessions of dialysis to remove impurities from their
blood. Prolonged dialysis can lead to deadly complications and decrease
the chances of a successful transplant later.
The problems
at Kaiser went beyond mere growing pains, current and
former employees said: Surgeons and kidney specialists battled over who
should receive transplants. Desperate patients complained of
inexplicable delays. Since the program opened, 10 permanent employees
have quit or been fired out of a staff of 22.
"On the
outside, the program
seems to have settled into a
reasonably functioning unit," kidney specialist Dr. W. James Chon wrote
to the hospital's physician-in-chief Jan. 23, not long before he was
placed on administrative leave.
"However, a
closer look at the program will show that it is suffering
from very serious and potentially explosive problems," he said.
In
interviews with The Times, Kaiser officials initially denied that
there were problems. "Everything has been going on track," head
transplant surgeon Arturo Martinez said last week.
Since then,
other officials have acknowledged that the program had
provided The Times with incomplete or misleading information. The chief
physician at Kaiser's main San Francisco hospital conceded that the
issues were "very serious."
"Time will
tell whether 'explosive' was an appropriate adjective or
not," said Dr. Bruce Blumberg, referring to Chon's letter.
But, he
said, the problems have not affected care for the patients on
the waiting list, now totaling about 2,000. No patients have died after
transplants, and surgeons hope to boost their output to about 90
transplants this year, Blumberg said.
"I'm very
pleased at the work done by the transplant program in the
first year," he said.
Kaiser's
troubled launch — coming to light after scandals
forced the
closure of two transplant programs in Southern California last year
—
underscores the dearth of oversight in the field of transplantation.
Leaders of
the United Network for Organ Sharing, the federally funded
group responsible for the nation's organ transplant system, said they
knew nothing of Kaiser's woes until The Times contacted them.
Dr. Andrew
Klein, director of transplant programs at Cedars-Sinai
Medical Center in Los Angeles and a member of the network's board, said
moving patients to new centers should never compromise the care they
receive.
Just
"because they had to
change centers they shouldn't have to change their [chances] of getting
transplanted," he said.
'Timing Was
Perfect'
The
jump into
transplants made good sense for Kaiser.
The San
Francisco hospital's open-heart surgery program was shrinking
as less-invasive procedures became more popular. Kaiser was left with
unused beds and operating rooms. By chance, Martinez, a transplant
surgeon at Sharp Memorial Hospital in San Diego, broached the idea with
Kaiser officials in early 2002.
"The timing
was perfect," Blumberg said.
In August
2003, officials told the media that they could do a better
job for their kidney transplant patients by working with the network of
doctors, labs and pharmacies serving Kaiser's 3.2 million members in
Northern California. (Kaiser still contracts with outside hospitals to
serve transplant patients in Southern California and elsewhere.)
"We should
be able to achieve higher outcomes," Dr. Sharon Inokuchi,
the transplant program's new medical director told the San Francisco
Business Times at the time. In the long run, officials said recently,
they believed they could save money too.
Kaiser
members are part of a unique healthcare entity that runs both a
health plan and a hospital system. Except in rare circumstances,
members get their care only from Kaiser hospitals and affiliated
Permanente medical group doctors.
In June
2004, Kaiser informed kidney patients on waiting lists at UC
San Francisco and UC Davis that from then on their transplants would
take place at Kaiser's hospital northeast of Golden Gate Park in San
Francisco. The first transplant was performed that October.
Relatives of
some patients recalled the letters offering no promises
and little comfort.
Patient
Rodney Clay's letter began with the salutation, "Dear Clay,
Rodney," and warned: "You will be financially responsible for any
kidney transplant services you receive from the University of
California, San Francisco, after Sept. 1, 2004."
Clay died in
September 2005 after being forced to move to Kaiser and
then being shifted back to UC San Francisco because of complications.
"It was just
messy the way that they handled it," said his wife,
Deborah. "We were in a state of shock."
Art Hanson
also complained about the handoff. He said his life partner,
Rodante Tolentino, "got in a snit" with Kaiser officials.
"They wanted
him to break his ties [with UC San Francisco] and have
nothing to do with them, and it was like, 'You either do what we say or
screw you,' " Hanson said. Tolentino, who had been on UC San
Francisco's list since 1998, grew tired of waiting and went to the
Philippines in search of a transplant last fall. By that time, he was
too sick, Hanson said. Tolentino refused dialysis and his medications
and died in November at age 61.
Hope
Turns to Dismay
Not
everyone was dismayed about
the switch to Kaiser.
When Ruben
Porras, a pressman at the Sacramento Bee, found out that he
was being transferred from UC Davis, his family thought it might
improve his chances of getting a transplant, said his wife, Elizabeth.
After three
years on the waiting list at UC Davis, he was close to
getting a new kidney there.
"It's
likely that he would have
been transplanted fairly soon,"
said Dr. Richard Perez, chief of the UC Davis transplant center.
The family's
anticipation soon turned to frustration.
"Nothing
happened," Elizabeth Porras said. "Everything stood still. I
lost faith in it all."
Although her
husband, who was in his 40s, was on the list for a cadaver
kidney, several of his relatives were willing to donate one of their
own kidneys, and UC Davis had been assessing them, she said. That
process halted when Kaiser took over Porras' case and relatives' calls
went unreturned, she added.
Porras and
66 other UC Davis patients unwittingly faced another
obstacle. Organs are distributed regionally, and the waiting time for a
kidney in the crowded San Francisco area is about double that in the
Sacramento area, where UC Davis is. Elizabeth Porras said her husband
was never told that his wait would jump from about three years to a
possible six with the move to Kaiser's new center.
The transfer
hurt Porras' chances in another way.
In the San
Francisco area,
kidneys are primarily allocated based
on how much time patients have spent on a master waiting list. When
patients switch to other programs, it is essential that they get credit
for the time they've already spent waiting. Otherwise it will appear
that they are new additions with no seniority, and their waits will
start from scratch.
In Porras'
case, Kaiser took nearly a year to transfer the time he had
spent on the waiting list at UC Davis, Perez said. That meant he landed
at the bottom of the list in the San Francisco area, putting a new
kidney out of reach any time soon.
The same was
true for hundreds of others at UC Davis and UC San
Francisco who were stranded between programs for months by Kaiser's
delays or paperwork snafus, the Times investigation found.
Even today,
UC San Francisco has about 220 Kaiser patients on its list
whose time has not been properly transferred to Kaiser, said Dr.
Stephen Tomlanovich, medical director of the university medical
center's renal transplant service.
Tomlanovich
said UC San Francisco has contacted Kaiser's Inokuchi or
her co-workers repeatedly by phone, fax and e-mail concerning the
patients. But Inokuchi said she has never heard from the university
hospital about these patients.
Regarding
Porras' case, Inokuchi said she could not comment because of
confidentiality restrictions.
But chief
surgeon Martinez
said, "We made every possible effort to make sure that people were not
caught in the middle."
Unaware of
this fumbling, Porras was tethered to dialysis, weathering
one complication after another.
"There's no
other life out there for you other than being treated," his
wife said. "He had no energy to do anything, go anywhere or do things
for himself."
Cost of
Survival Rate
One
statistic Kaiser proudly cites is its patients' survival rate
after transplantation: None of its patients have died in the year after
their surgeries.
"I got great
care there," said Hamilton Meek, 56, who got his kidney at
Kaiser in March. "I just knew it was a matter of time before I got the
kidney."
Maintaining
that survival record, however, appears to have come at a
price.
Through June
2005, Kaiser accepted only 16.7% of the kidney offers on
behalf of its patients, far less than neighboring programs: California
Pacific Medical Center accepted 29.5% and UC San Francisco 24.1% in the
same reporting period.
Many
experienced programs, with the consent of patients, also accept
organs from a separate pool of risky donors — older people,
for
instance, or people with health problems. The idea is to cut patients'
waits.
Kaiser
almost never tapped into this pool, which supplied kidneys for
15% of transplants in the Bay Area last year, according to the local
organ bank. Through December, Kaiser had accepted just one.
Kaiser
chief surgeon Martinez
said that's because only one patient had signed up.
Officials
from UC Davis and UC San Francisco said their numbers show
that many Kaiser patients had, in fact, been interested. At UC Davis,
before Kaiser started its program, 20 Kaiser patients had signed up for
the organs; at UC San Francisco, 23.
Ella Haynes
said her husband, Ronald, had signed up to receive two of
these riskier kidneys at UC Davis. But when he transferred to Kaiser,
the couple were told that the former Central Valley trucker "would be
better served to wait it out and get one good kidney."
"You just
believe what you hear and what you're told," Ella Haynes said.
In March
2005, her husband died of a blood infection.
Although he
never knew it, he didn't have a chance. His 2 1/2 -year
wait at UC Davis was never transferred to Kaiser, said Perez of UC
Davis, effectively shutting him out of a transplant.
Staff Infighting
Inside
the
Kaiser center, the stress of jump-starting the massive program took a
toll.
Although
Kaiser officials had brought in experienced physicians, much
of the core staff had never worked with transplant patients —
or one
another.
In early
2005, the program's first transplant administrator left.
Barely a year later, her replacement was terminated.
One kidney
specialist, Dr. Eric
Savransky, walked off the job this
February, cleared out his office and has not returned, colleagues said.
Officials say he is technically on leave.
Chon, the
physician who complained of potentially explosive problems,
was also put on leave in February after feuding with medical director
Inokuchi about the way the program was being run, current and former
employees said.
In
his January letter to the hospital's top physician, Chon
described staffers battling over which patients should receive
transplants.
One
73-year-old woman, he
wrote, had been waiting, initially at UC
San Francisco, since 1999. Chon said he and his colleagues felt that
although she was a high-risk patient, she was a viable candidate. But
Inokuchi refused to sign off, he wrote, until she saw additional
medical records — which Chon said were irrelevant.
"I truly
believe that
[Inokuchi's] decision to overrule four other
transplant physicians was unjust and unethical," he wrote in his letter.
In an
interview, Inokuchi said Chon had "incomplete information" and
could not make a proper assessment. Chon said he stands by his letter.
The
patient's daughter, Karen Sorensen, said she is incensed at
Kaiser's treatment of her mother, Corra Mayo. First, she said, no one
from the hospital tried to contact Mayo for eight months after she was
transferred from UC San Francisco, where she had been near the top of
the waiting list since early 2004.
Then,
Sorensen said, Kaiser staff couldn't find Mayo's medical records
and didn't return repeated phone calls. Finally, the daughter said, she
begged a receptionist for help and her mother got an appointment with
Chon.
"They had
too many people to
handle, and they don't know how to handle them," Sorensen said.
Mayo, now
74, has been undergoing dialysis three times a week. "It's
the worst way to live," Sorensen said. Late Monday, Mayo was called
into the hospital to be prepared for a transplant, but it is unclear
whether she will receive one.
Blumberg,
the hospital's
ranking physician, said the dispute over
Mayo's care demonstrates the staff infighting plaguing the program.
He also said
Inokuchi had been "relieved" of her administrative duties
to focus on patient care. He did not elaborate.
With all the
departures, Inokuchi is the only kidney specialist left to
manage patients' care in the hospital after their transplants, see them
for checkups,
handle
calls for medical advice, review lab results and evaluate patients.
Blumberg
said he is seeking additional kidney specialists, called
nephrologists, and has offers out to two.
Transplant
surgeons at other hospitals say programs of Kaiser's size
would have trouble functioning without at least four or five transplant
nephrologists. Cedars-Sinai, for example, has a waiting list less than
a quarter the size of Kaiser's but has three nephrologists and is
hiring a fourth.
Too Late for
Patient
That
Kaiser's
problems are now becoming public is of little comfort to Elizabeth
Porras.
Last fall,
her husband developed an infection related to his dialysis.
Despite attempts to treat it, he died Oct. 20 at age 47.
Each Sunday,
she takes roses to his grave.
Her last
contact with Kaiser came right after Ruben's death. A
representative called to ask if she would donate his organs.
"I was
really close to telling them, 'Yeah, you can have his kidneys,'
" she said.
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