Work­ers look to the bal­lot in dial­y­sis battle

Union files ini­tia­tives that would im­pose stricter rules for fees and staffing at clin­ics.

Los Angeles Times - - CALIFORNIA - By Melanie Ma­son

SACRA­MENTO — Crack­ing down on clin­ics treat­ing Cal­i­for­ni­ans with chronic kid­ney dis­ease has been a top leg­isla­tive pri­or­ity this year for unions rep­re­sent­ing health­care work­ers. Now they’re open­ing a new front in their cru­sade against the dial­y­sis in­dus­try: the bal­lot box.

Ser­vice Em­ploy­ees In­ter­na­tional Union-United Health­care Work­ers filed two ini­tia­tives with the state at­tor­ney gen­eral on Wed­nes­day that, if they qual­ify, would ap­pear on the Novem­ber 2018 bal­lot. The union is seek­ing to im­pose stricter rules at dial­y­sis cen­ters for the staffing lev­els and how much they charge.

The pro­pos­als closely re­sem­ble pend­ing bills that have thrust for-profit dial­y­sis cen­ters, which treat more than 63,000 Cal­i­for­ni­ans with end-stage kid­ney dis­ease, into the leg­isla­tive fray. By dan­gling the prospect of a bal­lot mea­sure as a backup plan, the union is fol­low­ing a well-worn path to spur leg­isla­tive ac­tion.

“We see it as a twopronged ap­proach,” said Sean Wher­ley, spokesman for SEIU-UHW. “We want to be sure we have as many op­tions avail­able as pos­si­ble.”

At issue are the cost and care stan­dards for treat­ing those ex­pe­ri­enc­ing kid­ney fail­ure, typ­i­cally due to di­a­betes or high blood pres­sure. Dial­y­sis per­forms some of the func­tion of kid­neys, such as re­mov­ing ex­cess salt and waste from the blood. Ses­sions are hours long and pa­tients usu­ally need treat­ments three times a week.

Two com­pa­nies, DaVita and Fre­se­nius, con­trol around 70% of the na­tional mar­ket, and a slightly higher per­cent­age in Cal­i­for­nia. That mar­ket share — cou­pled with the com­pa­nies’ high prof­its — has drawn scru­tiny re­cently, in­clud­ing an ex­tended look at the

in­dus­try on HBO’s “Last Week Tonight with John Oliver.”

The na­tional spot­light has co­in­cided with a vig­or­ous lob­by­ing push in Sacra­mento from health­care unions. Their first salvo was Se­nate Bill 349, by state Sen. Ri­cardo Lara (D-Bell Gar­dens), which would im­pose min­i­mum staffing ra­tios that would de­crease the num­ber of pa­tients a nurse or tech­ni­cian could care for. The pro­posal would also in­crease state in­spec­tions of dial­y­sis fa­cil­i­ties and would re­quire a 45-minute tran­si­tion time be­tween pa­tients. The mea­sure is await­ing ac­tion in the Assem­bly Ap­pro­pri­a­tions Com­mit­tee.

Pro­po­nents ar­gue that such re­forms are nec­es­sary to im­prove pa­tient safety. But de­trac­tors, in­clud­ing clinic op­er­a­tors as well as pa­tient groups and some physi­cians, say such reg­u­la­tions are un­nec­es­sary, ar­gu­ing that bet­ter staffing ra­tios have not been proved to lead to bet­ter care.

Op­po­nents also note that work­ers at dial­y­sis cen­ters hope to union­ize, which ex­plains la­bor groups’ keen in­ter­est in clinic op­er­a­tions.

Wher­ley said clinic staffers “want these re­forms re­gard­less of what hap­pens with their union ef­forts.”

A sec­ond mea­sure, in­tro­duced in June, would re­quire dial­y­sis clin­ics to spend at least 85% of their rev­enue on di­rect pa­tient care, qual­ity im­prove­ment in­vest­ments such as elec­tronic health records, and taxes and fees. If they don’t meet that re­quire­ment, they would need to issue re­bates to non­govern­men­tal health­care pay­ers, such as in­sur­ers.

That mea­sure, Assem­bly Bill 251 by As­sem­bly­man Rob Bonta (D-Alameda), has at­tracted op­po­si­tion from the dial­y­sis in­dus­try and hos­pi­tals.

That both bills re­main un­der con­sid­er­a­tion has not stopped SEIU-UHW from tele­graph­ing its plan B. The text of the ini­tia­tive states in its find­ings that “ef­forts to en­act pro­tec­tions for kid­ney dial­y­sis pa­tients in Cal­i­for­nia have been stymied in Sacra­mento by the dial­y­sis cor­po­ra­tions.”

Bonta said the ini­tia­tive threat brings an “ad­di­tional fo­cus” on clin­ics that could aid his leg­is­la­tion in the Capi­tol.

“It might make leg­is­la­tors think if this go­ing to hap­pen one way or the other, it may be best for us to help craft it and shape it and make it the best pos­si­ble … to sup­port pa­tient care,” said Bonta, adding that the ini­tia­tive might sim­i­larly in­spire in­dus­try op­po­nents to en­gage on his bill.

The bal­lot mea­sure is not iden­ti­cal to the leg­is­la­tion. In­stead of re­quir­ing that 85% of a dial­y­sis cen­ter’s rev­enue be spent on pa­tient care, as Bonta’s bill would do, the ini­tia­tive would re­quire clin­ics to issue re­bates if they charge more than 115% of the av­er­age treat­ment cost in the state. Both poli­cies would in ef­fect limit dial­y­sis cen­ters’ spend­ing on items other than pa­tient care — such as ex­ec­u­tive com­pen­sa­tion — to no more than 15% of prof­its.

SEIU-UHW has filed two ver­sions of the ini­tia­tive, re­flect­ing con­tin­gency plans for var­i­ous sce­nar­ios. The first would in­clude both the staffing-ra­tio re­quire­ment and the cap on charges; the sec­ond would deal only with the costs in case SB 349, with its staffing reg­u­la­tions, is signed into law. The union aims to place only one mea­sure on the bal­lot.

Kathy Fair­banks, a spokes­woman for op­po­nents of the dial­y­sis leg­is­la­tion, de­nounced the fil­ing of the mea­sures, ac­cus­ing the la­bor group of us­ing “the ini­tia­tive process to put their union mem­ber-build­ing agenda ahead of what’s good for pa­tients.”

“While fil­ing an ini­tia­tive is only the first step in a long process, these ini­tia­tives would be dan­ger­ous for pa­tients by re­duc­ing ac­cess to life-sav­ing dial­y­sis care,” Fair­banks said in a state­ment. “That’s why these poli­cies are op­posed by doc­tors, dial­y­sis clinic work­ers, pa­tients, veter­ans, nurses and many oth­ers. It’s shame­ful that this or­ga­ni­za­tion would threaten to put the lives and qual­ity care of tens of thousands of dial­y­sis pa­tients at risk just to fur­ther their own agenda.”

The early fil­ing date of­fers an­other ben­e­fit to the union: a cheaper route to the bal­lot. Col­lect­ing sig­na­tures tends to get pricier as the qual­i­fi­ca­tion dead­line ap­proaches.

SEIU-UHW is no stranger to us­ing the prom­ise of a loom­ing bal­lot ini­tia­tive to ac­com­plish pol­icy goals. In 2013, the union threat­ened two mea­sures on hos­pi­tal pric­ing and ex­ec­u­tive pay, while the la­bor group squab­bled with hos­pi­tals on or­ga­niz­ing op­por­tu­ni­ties.

In 2016, the union was one of two la­bor groups to in­tro­duce pro­posed bal­lot mea­sures to raise the state min­i­mum wage. The ini­tia­tives prod­ded Gov. Jerry Brown and law­mak­ers to take ac­tion on their own, ul­ti­mately craft­ing com­pro­mise leg­is­la­tion rais­ing the wage to $15 an hour.

The deal was made pos­si­ble by a 2014 law that al­lows back­ers to with­draw a mea­sure even af­ter it has qual­i­fied for the bal­lot. The change, said UC San Diego po­lit­i­cal sci­ence pro­fes­sor Thad Kousser, “gives in­cen­tive to the Leg­is­la­ture to come to the ta­ble.”

Kousser said the in­ter­play be­tween leg­is­la­tion and ini­tia­tive long pre­dates the 2014 over­haul of the rules. Early pro­po­nents of bal­lot mea­sures called the op­tion “the gun be­hind the door,” he noted, prod­ding the Leg­is­la­ture to act.

“It’s been used like that for 100 years,” Kousser said.

Ir­fan Khan Los An­ge­les Times

GI­RALDO GAR­CIA, 54, un­der­goes kid­ney dial­y­sis at a clinic in In­gle­wood. Two com­pa­nies, DaVita and Fre­se­nius, con­trol around 70% of the na­tional mar­ket, and a slightly higher per­cent­age in Cal­i­for­nia. That mar­ket share — cou­pled with high prof­its — has drawn scru­tiny.

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