PDF Summary:How to Make a Killing, by Tom Mueller

How did a therapy intended for the public good become a business driven by profit motives? In How to Make a Killing, Tom Mueller chronicles the birth of dialysis, a pioneering treatment that replaced the kidney function with machinery and revolutionized nephrology. He examines the ethical debates sparked by this novel therapy, including how to ration the limited treatment, and dialysis's role in exposing racial inequities in American healthcare.

Mueller also dissects how dialysis corporations like DaVita and Fresenius prioritized profits over patient welfare, compromising care quality for dialysis recipients. The book explores reform efforts to curb corporate abuses and improve dialysis, illustrating broader issues in the commercialization of U.S. medicine.

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Practical Tips

• You can support local access to healthy food by starting a community garden exchange program. Find neighbors or community members who are interested in gardening and coordinate a system where each person grows different types of produce. Then, set up regular exchange days where everyone can trade their surplus with others, ensuring a diverse range of healthy foods is available to all participants.
• Volunteer your time with local organizations that focus on bridging educational gaps. By offering to tutor or mentor, you contribute to leveling the playing field for individuals in these communities. This personal involvement can have a direct impact on someone's educational journey and future opportunities.
• You can support local businesses in underserved communities by consciously redirecting your purchasing habits. By choosing to buy from small businesses in areas affected by disinvestment, you're directly contributing to their economic growth. For example, instead of buying coffee from a large chain, find a local café in a disadvantaged area and become a regular customer.

Other Perspectives

• Personal lifestyle choices, such as diet and exercise habits, can have a substantial impact on the development of these illnesses, independent of socioeconomic factors.
• The focus on hypertension and diabetes might inadvertently minimize the importance of early detection and management of kidney disease, regardless of the underlying cause.
• Advances in telemedicine and community health initiatives may be providing support for chronic disease management and prevention in ways that are not captured by the presence of physical dialysis clinics.

Racial Disparities in Dialysis: Waitlists to Mortality

Mueller presents a disturbing array of evidence demonstrating how racial disparities permeate every stage of dialysis treatment in America. He highlights how African Americans, despite representing a disproportionately large portion of those receiving dialysis, face consistently worse outcomes compared to white individuals: experiencing longer wait times to be placed on transplant lists, lower transplant rates, a greater likelihood of being dialyzed in substandard facilities, higher rates of hospitalization and infection during treatment, and ultimately, higher mortality rates. Even the calculation for estimated glomerular filtration rate (eGFR), the algorithm utilized to evaluate kidney function, is improperly altered based on race, a practice that Mueller argues has further disadvantaged Black patients.

Mueller argues that these stark disparities cannot be explained solely by socioeconomic factors, but rather reflect a web of intersecting biases, including implicit bias among healthcare providers, systematic underfunding of dialysis-related programs in minority communities, and a cultural legacy of medical experimentation and mistreatment of people of color. This failure to provide equitable dialysis care, Mueller contends, underscores the deep-seated structural racism that continues to plague American medicine, undermining dialysis's initial pledge to extend life and well-being for all Americans with kidney failure.

Practical Tips

• Support organizations that work to improve equity in healthcare. Research and donate to nonprofits that are actively working to address disparities in transplant lists and healthcare access. Your financial support can help fund initiatives that aim to create a fairer system for all patients in need.
• You can raise awareness by sharing information on social media about the importance of organ donation, specifically highlighting the disparities in transplant rates. Create a simple infographic or shareable post that explains the issue in an accessible way, encouraging your network to register as organ donors and to discuss their wishes with family members.
• Start a virtual book club focused on health and wellness, inviting a diverse group of participants. Choose books that offer insights into maintaining good health and preventing diseases, especially those prevalent in African American communities. This can foster a supportive environment where members can share tips, encourage healthy habits, and create accountability.
• Support kidney health research that focuses on developing more inclusive and accurate eGFR calculations by participating in surveys or studies if opportunities arise. Researchers often need diverse data sets to refine their models, and by contributing your health information (with appropriate privacy considerations), you can help advance the science toward more personalized and fair assessments of kidney function.
• Volunteer as a patient advocate at local clinics or hospitals to help patients navigate their healthcare experiences. As an advocate, you can ensure that patients receive fair and unbiased treatment by being present during medical appointments, asking questions, and providing support. This role allows you to observe interactions between healthcare providers and patients, potentially identifying instances of implicit bias and working to mitigate its effects.
• Educate yourself on the history of medical experimentation by reading articles and watching documentaries that focus on the experiences of people of color. This will give you a broader understanding of the context behind current healthcare disparities and can inform your conversations and actions regarding healthcare equality.

The Influence of Dialysis Corporations on the Standard of Care and Allegations of Misconduct

This section explores the emergence of profit-oriented dialysis providers in America, specifically DaVita and Fresenius, and their impact on the quality of dialysis care. Mueller chronicles how a medical therapy envisioned as both an ethical imperative and a symbol of social progress became, in the hands of corporate America, a lucrative business operation increasingly defined by a focus on financial returns instead of patients' welfare.

Dialysis Industry Dominated by For-profit Providers Davita and Fresenius

Mueller documents the transformation of American dialysis from a nascent medical specialty, driven by research and innovation at university medical centers, into a multibillion-dollar industry dominated by two for-profit corporations, DaVita and Fresenius. He describes the aggressive consolidation of the dialysis market through mergers and acquisitions, during which larger firms absorbed smaller, often independent, units, steadily increasing the market share controlled by DaVita and Fresenius. This evolution, Mueller argues, had profound ramifications for how dialysis care was practiced, funded, and regulated in America.

Corporations Adopted Cost-Cutting Business Models From Other Industries, Prioritizing Efficiency and Profit Rather Than Patient Care in Dialysis

Mueller examines how companies offering dialysis, following a script familiar to many other industries, adopted cost-cutting business models, prioritizing efficiency and profit over individualized patient care. He describes how nephrology clinics, historically owned and operated by individual physicians or small groups of partners, were increasingly acquired by the corporate giants, often with lucrative payouts to the original owners. The corporate managers, applying techniques drawn from industrial efficiency models, then implemented standardized protocols, shortened treatment times, increased patient-staff ratios, and minimized expenditures related to hygiene, maintenance, and supplies.

This focus on economic metrics, Mueller argues, had detrimental effects on patient health, as the complex needs of individual patients were frequently overshadowed by a standardized delivery of dialysis. Mueller also chronicles how financialization of healthcare changed nephrologists' roles, as doctors who had once managed their own clinics were now increasingly beholden to corporate managers, and incentivized to prioritize corporate profitability over the health and well-being of their patients.

Other Perspectives

• Increased patient-staff ratios might be a reflection of improved technologies and treatment methods that allow staff to effectively care for more patients without a decrease in the quality of care.
• The acquisition of nephrology clinics by larger entities can provide nephrologists with more resources for research and professional development, potentially advancing the field of nephrology.
• Cost-cutting measures might be a response to external pressures such as reduced insurance reimbursements or government funding, which require organizations to find ways to sustain operations without compromising patient care.
• Standardized protocols can lead to more consistent and predictable patient care, which can be beneficial in managing a large number of patients with similar conditions.
• Nephrologists, like all medical professionals, are bound by ethical standards and the Hippocratic Oath, which prioritize patient care above all else, suggesting that despite financial pressures, patient well-being remains a central concern.

Informants and Investigators Uncover Corporate Misconduct: Fraud, Kickbacks, and Neglect of Patient Welfare

Mueller details a disturbing pattern of purported wrongdoing by corporate dialysis providers, as uncovered by whistleblowers and government investigators. He cites numerous lawsuits, investigations, and criminal charges brought against both DaVita and Fresenius, involving allegations of defrauding federal health insurance programs, illegal kickback schemes, bribery of physicians, and deliberate cherry-picking of more lucrative patients in better health. Mueller highlights how these companies, despite paying large financial penalties, consistently denied wrongdoing, often continuing their questionable practices despite judicial scrutiny, suggesting a culture of impunity within the industry.

These cases, Mueller argues, reveal how the emphasis on constant profit growth, mandated by investor expectations and embodied in many corporate performance metrics, can create powerful incentives to cut corners, manipulate data, and prioritize financial gains above patients' health. The recurring pattern of alleged misconduct by dialysis companies mirrors the evolution of other segments of American healthcare, where corporatization, privatization, and the ascendancy of investor-owned medicine have led to a growing tension between business practices and medical ethics.

Practical Tips

• Volunteer with a non-profit organization that focuses on corporate accountability. By offering your time and skills, you can contribute to the efforts of organizations that work to uncover and combat corporate misconduct. This could involve anything from administrative support to participating in awareness campaigns, giving you practical experience in the field of corporate ethics.

Other Perspectives

• The continuation of practices deemed questionable could be due to ambiguities in regulations or legal standards, which companies may interpret differently than regulators or prosecutors.
• Financial gains can be reinvested into research and development, improving the quality of care and expanding access to cutting-edge medical technologies.
• Financial penalties for misconduct suggest that there is some level of accountability in the industry, which contradicts the notion of a pervasive culture of impunity.
• The assertion that the pattern of misconduct reflects broader issues in American healthcare could be seen as an overgeneralization, as each segment of healthcare has its own regulatory environment, competitive dynamics, and ethical considerations.
• The regulatory framework, rather than the ownership model, plays a crucial role in ensuring that ethical standards are upheld; with robust oversight, private companies can be held accountable for their practices just as effectively as public entities.

Corporate Dialysis Providers' Profit-Driven Models Reduced Care Quality

Mueller describes how the profit-driven models of corporate dialysis providers have led to a progressive decline in the quality of dialysis care, compromising patient outcomes and creating an environment in which some patients experience neglect, abuse, and retaliation. Mueller highlights the systematic use of high-speed dialysis, with shortened therapy durations and elevated UFR, a practice designed to increase patient throughput and maximize profits, but which, according to decades of medical research, has grave consequences for patient wellbeing, leading to debilitating side effects, higher rates of hospitalization, and increased mortality.

Dialysis Clinics Adopted High-Speed, High-Volume Dialysis, Compromising Patient Safety

Mueller examines how large dialysis corporations, driven by a focus on efficiency and profit maximization, commonly employ a form of treatment that expert nephrologists condemn as dangerous and sometimes lethal. Their reliance on high-speed, high-volume dialysis, with shortened treatment times and elevated UFR, allows clinics to treat additional patients daily on each dialysis machine, thereby increasing revenues and profitability. But as Mueller stresses, the faster and sharper these processes, the more likely a patient will experience a range of debilitating side effects, including nausea, headaches, cramps, abrupt blood pressure declines, organ damage, and even cardiac arrest.

Mueller contrasts the corporate approach in America with dialysis care in many other nations, highlighting the prevalence of long, slow treatments and careful fluid management in high-quality centers in Europe, Australia, and elsewhere, which have demonstrably higher survival rates and better patient outcomes. Mueller argues that the American fixation with rapid treatment, centered on a flawed reliance on the urea clearance metric known as Kt/V, reflects a corporate mindset that places profits ahead of patient safety, treating people receiving dialysis as products on an assembly line rather than individuals whose health requires meticulous care.

Other Perspectives

• Clinics may argue that their high-speed, high-volume practices are a result of financial pressures from insurance companies or government healthcare systems that incentivize shorter treatment times.
• Some patients may tolerate high-speed, high-volume dialysis well due to individual differences in physiology and may not experience the debilitating side effects mentioned.
• The Kt/V metric, while not perfect, is a widely accepted measure of dialysis adequacy, and its use in guiding treatment intensity is based on a substantial body of research; alternative metrics or approaches may not have the same level of evidence or may not be as practical in a clinical setting.
• The association between treatment duration and better outcomes could be confounded by other factors, such as overall quality of care, patient selection, or adherence to treatment protocols, which might differ across countries.
• Rapid treatment protocols may be a response to the needs of certain patient populations who require flexibility due to work, family, or other personal commitments.
• The focus on profit can incentivize dialysis clinics to maintain high standards of care to attract and retain patients in a competitive healthcare market.
• It could be argued that the focus on metrics like Kt/V is not solely a corporate mindset but also a response to regulatory requirements and medical guidelines that emphasize quantifiable outcomes.

Providers Prefer Lucrative Privately-Insured Patients Over Government-Insured Ones

Mueller reveals another consequence of the profit-driven mentality: a clear preference for high-margin patients with private insurance — often referred to at DaVita as “HIPPERs,” for “high-paying patients” — over those covered by public insurance programs like Medicare and Medicaid. He explains how the disparity in reimbursement rates between private and government insurance creates powerful incentives for dialysis providers to prioritize clients who generate the highest profits, leading to preferential treatment for HIPPERs, and a second-class status for many publicly insured patients.

Mueller cites evidence of systematically directing new dialysis patients to avoid government insurance plans in favor of higher-paying private coverage, which may involve monetary aid from the American Kidney Fund (AKF), a non-profit foundation that has faced allegations of colluding with dialysis companies to maximize profits. This arrangement, according to Mueller, not only disadvantages patients covered by government insurance by potentially delaying their access to organ transplants and raising personal costs, but also further destabilizes the US healthcare system by forcing public programs to bear a disproportionate share of the cost burden.

Practical Tips

• Create a community support group for patients with chronic illnesses to share information and resources about navigating the healthcare system. Within this group, members can exchange tips on how to deal with providers that may prioritize certain patients, and compile a list of patient-friendly providers. This collective knowledge can empower group members to make better-informed decisions about their healthcare and advocate for each other.
• Educate yourself on the differences between government and private insurance plans by using online comparison tools. Many websites offer side-by-side comparisons of insurance plans, including coverage details and costs. By inputting your specific health needs, such as dialysis, you can get a clearer picture of which plan may be more beneficial for you.
• Start a blog or social media page focused on sharing stories and resources related to kidney health insurance options. Use this platform to highlight different pathways to coverage, including nonprofit assistance, and share success stories of individuals who have navigated the system effectively. This can serve as a peer-to-peer support network, encouraging others to explore their options and potentially connect with organizations that can assist them.
• Create a personal health savings account specifically for transplant-related expenses. Start setting aside a small, manageable amount of money each month into this account. This proactive financial planning can help you cover unforeseen costs that might not be fully covered by insurance. Consider using online budgeting tools or apps that allow you to earmark funds for health-related savings, ensuring you have a dedicated resource pool if the need arises.
• You can scrutinize healthcare providers by comparing their services and costs online to ensure you're not overpaying. Look for websites that offer cost comparisons for medical procedures and check if the prices align with the average in your area. If you find a significant discrepancy, it might indicate a lack of competition or possible collusion.

Reforming and Regulating Dialysis Industry's For-Profit Model and Its Societal Impacts

This final section explores efforts to reform and impose regulations on the commercial dialysis industry, detailing the challenges and successes of various initiatives aimed at improving patient care and curbing abuses. Mueller highlights the essential contributions of patient advocates, labor unions, whistleblowers, and several principled nephrologists in exposing the industry's shortcomings and demanding changes. He also examines the broader implications of privatized healthcare in America, depicting the dialysis sector as a warning of the potential for corporate profiteering to undermine the ethical foundation of medicine.

Lawmakers, Advocates, and Workers Pursue Policy and Legal Measures to Improve Care for Dialysis Recipients and Curb Abuses

This section chronicles the ongoing struggle to reform dialysis care in America. Mueller details a wave of recent initiatives, laws, and legal challenges aimed at curbing corporate abuses, bolstering oversight, improving staffing ratios, and protecting the rights of vulnerable patients. Mueller underscores the resilience and determination of advocates, workers, and lawmakers seeking to make dialysis treatment better, even as he acknowledges the immense power of the entrenched dialysis lobby and its formidable war chest, which has consistently sought to suppress change and maintain the status quo.

Initiatives, Laws, and Legal Challenges Target Oversight, Employee Numbers, and Limiting Business Profits

Mueller describes a spectrum of reform initiatives, ranging from grassroots efforts by patient advocacy groups like Dialysis Advocates to statewide ballot initiatives in California championed by SEIU-UHW, and culminating in the landmark DaVita v. Marietta Memorial Hospital case before the US Supreme Court. These initiatives have targeted a range of problems within the industry, seeking to strengthen oversight and enforcement by CMS and the ESRD networks, improve clinic hygiene and sanitation, require higher staffing ratios with more experienced nurses, limit corporate profits, and prevent discrimination against patients based on their insurance status.

Mueller also highlights how federal and state lawmakers have introduced several bills aimed at increasing the availability of at-home dialysis, a less expensive and often safer alternative to in-center treatment, and bolstering the national organ procurement system to increase the number of kidney transplants. These legislative efforts, as Mueller explains, often face stiff opposition from dialysis companies, which have consistently used their political muscle to defend their practices aimed at maximizing profits.

Practical Tips

• Create a discussion group with friends or colleagues to analyze and debate the outcomes of various court cases. Each member could present a different case, outlining the key legal principles and decisions involved. This activity will help you develop critical thinking skills and a deeper appreciation for the complexities of the law.
• Educate yourself on the specifics of healthcare oversight by enrolling in a free online course or webinar. Look for courses that cover topics such as healthcare management, patient safety, and quality improvement. This self-education will empower you to make informed decisions about your healthcare and to advocate for strong oversight practices in your interactions with healthcare providers.
• Create a feedback system using free online survey tools to gather patient opinions on clinic sanitation and staffing. Distribute the survey link to clinic visitors or post it in waiting areas, ensuring anonymity to encourage honest feedback. The collected data can then be shared with clinic administrators to highlight areas for improvement.
• You can support businesses that prioritize ethical practices by choosing where you shop. Look for companies that openly share their profit margins and have clear non-discrimination policies. By spending your money at these businesses, you're voting with your wallet for the kind of corporate behavior you want to see.

Dialysis Industry Resists Reform Via Lobbying and Retaliation

Mueller documents how Big Dialysis, represented by its powerful trade associations and armed with virtually unlimited lobbying funds, has consistently resisted reform efforts by any means necessary. He reveals how dialysis businesses have poured millions of dollars into campaign contributions, lobbying efforts, and public relations campaigns to influence legislation, sway policymakers, and shape public discourse. They've skillfully exploited patient anxieties and fears to discredit proposed legislation, deployed sophisticated misinformation strategies, and cast advocates and workers seeking to improve dialysis safety as dangerous radicals who threaten patient lives.

Mueller also describes how dialysis companies have retaliated against employees and patients who raised concerns about substandard care or wrongdoing. He cites cases of people fired for voicing their concerns, nurses threatened with career termination, and even patients involuntarily discharged from dialysis, a virtual death sentence, for the "crime" of challenging the authority of their caregivers or filing complaints with state and federal oversight bodies. These acts of retaliation, Mueller argues, underscore the industry's primary purpose: to protect profits, even to the detriment of patient well-being.

Practical Tips

• Engage in conversations with healthcare professionals about the quality and accessibility of dialysis treatment. When you visit a doctor or a healthcare facility, ask questions about their views on dialysis treatment options and what changes they think could improve patient care. This can give you insights into the real-world impacts of lobbying and potential areas for reform.
• Develop a habit of questioning the motives behind public relations campaigns by local companies. Whenever you see a PR campaign, take a moment to research the company's recent activities, including any legislation they might benefit from. This critical approach helps you become a more informed consumer and citizen, aware of the potential hidden agendas in corporate messaging.
• Educate yourself on healthcare legislation by subscribing to a nonpartisan newsletter that focuses on health policy. By staying informed about the latest proposals and the arguments for and against them, you can develop a more nuanced understanding of how companies might influence public opinion and what the actual impacts of legislation might be.
• Engage with friends or family members in role-play scenarios where one person presents an argument laced with misinformation, and the other practices responding with fact-based counterarguments. This activity not only helps in recognizing misinformation strategies but also improves your ability to communicate effectively in defending the truth.

The Failings of Commercial Dialysis Reflect Broader American Healthcare Issues

This final section steps back from the complexities of dialysis and examines the industry's failures as symptomatic of deeper, systemic problems within the US healthcare system as a whole. Mueller argues that the corporate capture of dialysis, with its profit-driven model and attendant abuses, exemplifies a broader trend of financialization and corporatization within American medicine, a shift that has significantly eroded the ethical foundation of healthcare and compromised the well-being of those it claims to serve.

Financialization and Corporatization of Medicine Undermine Patient Wellbeing In Dialysis

Mueller argues that the for-profit dialysis industry is a stark example of how financialization and corporatization of medicine can undermine patients' welfare and distort medical ethics. He highlights the increasing dominance of investor-owned healthcare companies, whose primary focus on financial returns often clashes with the long-term commitment to providing care and the physician's pledge to "do no harm first." The proliferation of assembly line healthcare models, prioritizing efficiency and standardization over individualized care, has, according to Mueller, led to a decline in quality and a corresponding rise in costs throughout the American healthcare system.

Mueller points to the example of private equity (PE) firms, whose aggressive cost-cutting and asset-stripping tactics have wreaked havoc on hospitals, care facilities for the elderly, and other healthcare sectors. He emphasizes that PE firms, with their short time horizons and relentless drive for profit, fundamentally clash with quality healthcare that prioritizes patient well-being. The trend towards further financialization in healthcare, Mueller contends, suggests a bleak future for American medicine if fundamental reforms aren't undertaken.

Context

• The shift towards for-profit healthcare in the U.S. began in the late 20th century, influenced by broader economic trends and changes in healthcare policy, such as the rise of managed care.
• The influence of investor-owned companies can extend to lobbying efforts that shape healthcare policies and regulations, potentially prioritizing industry interests over patient protection and access to care.
• This term refers to a system where medical services are delivered in a highly standardized and streamlined manner, similar to a factory assembly line. The focus is on maximizing throughput and efficiency, often at the expense of personalized patient care.
• PE acquisitions can lead to increased market consolidation, reducing competition and potentially leading to higher prices for services, which can affect accessibility and affordability for patients.
• The typical investment horizon for private equity is around 3 to 7 years, which may not align with the long-term nature of healthcare improvements and patient outcomes, leading to decisions that prioritize immediate financial returns over sustainable healthcare practices.
• Reforms could include stricter regulations on financial practices in healthcare, incentives for patient-centered care, and policies that ensure transparency and accountability in healthcare management.

Dialysis Outcomes Reflect Racial Disparities, Cost Rationing, and "Fast-Food" Healthcare Models in American Medicine

In his final analysis, Mueller argues that the failures of commercialized dialysis mirror broader failures in the American healthcare system as a whole. He identifies three fundamental problems that have contributed to this situation: pervasive racial and socioeconomic disparities in access to care and quality of treatment; implicit and explicit rationing of healthcare resources based on cost considerations and insurance status; and the proliferation of quick-fix healthcare models, which prioritize quick, standardized procedures over individualized care and long-term health outcomes.

The trio of problems, as Mueller clearly demonstrates, are inextricably linked. The elevated price of healthcare in America, combined with the absence of universal coverage, necessitates rationing, creating a two-tier system where those with greater resources and insurance are privileged over those who rely on public programs or are uninsured. This rationing, in turn, often falls along racial and socioeconomic lines, as a legacy of systemic injustices has left marginalized communities disproportionately vulnerable to chronic illnesses, like kidney disease, and underserved by healthcare services. Mueller argues that addressing these fundamental flaws will require a bold reimagining of healthcare in America—a return to focusing on patients, emphasizing preventive care, and committing to equitable access and treatment for all Americans, regardless of race, income, or zip code.

Context

• Systemic racism refers to the policies and practices entrenched in established institutions, which result in the exclusion or promotion of designated groups. In healthcare, this can manifest as unequal treatment and access to services for racial minorities.
• These models are often driven by the need for efficiency and profit in a privatized healthcare system. They can lead to a focus on treating symptoms rather than addressing underlying health issues, which may result in repeated hospital visits and higher long-term costs. This approach can undermine the doctor-patient relationship, reducing opportunities for personalized care and comprehensive treatment plans.
• Universal healthcare coverage refers to a system where all individuals have access to necessary healthcare services without financial hardship. Countries with universal coverage often have better health outcomes and lower overall healthcare costs.
• Marginalized groups frequently encounter obstacles in accessing healthcare services, such as fewer healthcare facilities in their neighborhoods, lack of transportation, and language barriers, which can delay diagnosis and treatment.
• This involves measures taken to prevent diseases rather than treating them after they occur. It includes regular screenings, vaccinations, and lifestyle counseling to reduce the risk of chronic diseases, ultimately aiming to improve long-term health outcomes and reduce healthcare costs.