How to Make a Killing

1. The US Dialysis Industry: A Lucrative Duopoly Built on Compromised Care

Who knew there was so much money to be made in dialysis?

Dominant players. The American dialysis industry is largely controlled by two publicly traded multinationals, Fresenius and DaVita, which together operate approximately 80% of the nation's clinics and capture a similar share of its revenues. This duopoly has consistently posted massive profits year after year, despite facing repeated allegations of healthcare fraud and other serious wrongdoing. The sheer scale of their financial success in a life-sustaining medical field is striking.

Fraud and settlements. These dominant companies have been subject to numerous legal challenges, resulting in substantial settlements totaling hundreds of millions, even billions, of dollars. These settlements address allegations ranging from illegal kickbacks to overbilling Medicare and manipulating financial statements. Despite these significant penalties, the companies continue to thrive, suggesting that for them, such legal costs are merely a predictable expense of doing business.

Distorted promise. Dialysis was once hailed as a miracle cure, a technological breakthrough that replaced a vital organ and prompted the birth of bioethics. In the early 1970s, Congress even pledged to pay for treatment for nearly all Americans with kidney failure, making it the country's first and only major experiment in "Medicare for All." However, this noble vision has been profoundly distorted by the for-profit model, transforming a life-saving therapy into an extractive corporate enterprise.

2. "Bazooka Dialysis" Prioritizes Speed and Profit Over Patient Health

The survival rate in the United States, where around 22 percent of patients die every year, is the lowest in the industrialized world.

Dangerous practices. In the United States, dialysis treatments are often too short and fast, a method dubbed "bazooka dialysis" by some nephrologists. This approach, characterized by brief durations and high ultrafiltration rates (UFR), is medically harmful, particularly for smaller patients. Decades of research demonstrate that rapid fluid removal can trigger sudden drops in blood pressure, damaging the heart, brain, gut, and lungs, and leading to severe complications like stroke and cardiac arrest.

Compromised care. This high-speed model also exacerbates debilitating side effects such as vomiting, fainting, leg cramps, and "dialysis fog," turning each session into a physical and psychological ordeal. While high-quality, nonprofit centers in the U.S. and many European countries offer slower, gentler treatments that improve patient outcomes and quality of life, corporate dialysis prioritizes processing more patients per day to maximize profits, often at the expense of patient well-being.

Global disparity. The stark contrast in patient survival rates between the U.S. and other industrialized nations underscores the problem. While the U.S. sees approximately 22% of dialysis patients die annually, Japan's mortality rate is 5-6%, and Western Europe's is 9-12%. This significant difference is largely attributed to the prevalence of for-profit dialysis in America, where the relentless pursuit of earnings often leads to medically harmful practices and a lower standard of care.

3. Vulnerable Patients Face Involuntary Discharge and "Blackballing"

For many patients, dialysis in an emergency room is a death sentence of six to twelve months.

Punitive terminations. Patients who question the quality of their care, report sanitation hazards, or challenge clinic practices often face involuntary discharge. These terminations are frequently preceded by accusations of "disruptive behavior" or "verbal aggression," sometimes fabricated or exaggerated, to create a paper trail justifying the removal of "undesirable" patients. This punitive approach leaves patients in a terrifying medical limbo.

Life-threatening consequences. Once discharged, patients are often "blackballed" by other facilities, which refuse treatment based on the negative reports in their medical files. This forces them into emergency room dialysis, a sporadic and dangerous form of care that only occurs when their condition becomes critical. Such emergency-only treatment is associated with significantly higher mortality rates, effectively becoming a death sentence for many.

Targeting the marginalized. Involuntary discharges disproportionately affect lower-margin patients, particularly those covered by government programs like Medicare or Medicaid, who are less profitable than privately insured individuals. This practice highlights a caste system within dialysis, where patient welfare is secondary to financial considerations, and those who are already vulnerable are further exploited and denied essential, life-sustaining care.

4. Financial Incentives Distort Medical Ethics and Treatment Decisions

Nephrologists contributed to killing their patients, for money.

EPO overprescription. The story of erythropoietin (EPO) vividly illustrates how financial incentives corrupt medical practice. When Medicare reimbursement for EPO shifted from a blanket fee to a per-dose payment, dialysis companies profited from the spread between purchase and reimbursement prices. This led to a dramatic increase in EPO usage, despite accumulating clinical evidence that high doses could cause deadly side effects like stroke and cardiac arrest, until reimbursement policies changed again.

Flawed metrics. The industry's fixation on Kt/Vurea as the definitive measure of dialysis quality, established by guidelines often influenced by industry-funded experts, further distorts care. While convenient, Kt/V is a poor measure of comprehensive dialysis quality, overlooking crucial factors like fluid balance and the removal of other, more harmful toxins. This narrow focus enables short, high-speed treatments that maximize turnover and profit, even if they compromise patient health.

Complicit physicians. Many nephrologists, especially those with financial stakes in dialysis facilities, tacitly accept corporate treatment protocols designed to maximize revenue rather than health. While theoretically responsible for individualized patient care, they often face pressure to approve higher drug dosages or shorter treatment times. This creates a profound conflict of interest, leading some to prioritize financial gain over their Hippocratic oath, with devastating consequences for patients.

5. Regulatory Oversight is Weak, Ineffective, and Industry-Influenced

The whole notion of how dialysis units are reviewed may itself benefit from an in-depth review.

Compromised watchdogs. The ESRD Networks, contractors hired by CMS to regulate the dialysis industry, frequently fail to protect patients. Instead, they are often perceived as siding with dialysis companies, sometimes even coaching clinics on proper termination protocols for "difficult" patients. This complicity undermines their mandate to ensure quality care and leaves patients without an effective recourse for grievances.

Facade of compliance. State agencies responsible for inspecting dialysis facilities are chronically underfunded, leading to infrequent and inadequate investigations. Clinics are often tipped off about "surprise" inspections, allowing them to temporarily boost staffing and hygiene to present a favorable image. Furthermore, data manipulation, or "buffing the numbers," is reportedly common, with clinics altering lab results to appear compliant with quality metrics and avoid penalties.

Revolving door. The close ties between regulators and the regulated are evident in the "revolving door" phenomenon, where former government officials transition to lucrative positions on dialysis company boards, and vice versa. This creates an environment where industry interests can heavily influence policy decisions, leading to lax oversight and regulations that favor corporate profits over patient safety and well-being.

6. Corporate Culture Normalizes Unethical Practices and Suppresses Dissent

To see how committed you were, people inside the company would literally ask, ‘Have you drunk the Kool-Aid?’

Cult-like environment. DaVita, one of the industry's giants, cultivates a highly distinctive corporate culture, referring to itself as a "Village" and its employees as "teammates" or "citizens." This environment, borrowing elements from military units, tribes, and religious practices, aims to foster intense loyalty and commitment. Employees are encouraged to participate in elaborate skits, chants, and rallies, creating a sense of belonging that can border on cult-like devotion.

Contempt for oversight. This culture, however, also appears to normalize a dismissive attitude towards external oversight. A notorious "Musketeer Skit" depicted senior executives, dressed as musketeers, "murdering" characters representing federal prosecutors, government regulators, and insurance executives. This theatrical display, met with cheers from employees, starkly revealed a corporate mindset that views regulatory bodies as adversaries to be vanquished, rather than partners in ensuring ethical healthcare.

Moral injury. The "Tone at the Top" and the "framing effect" within such organizations can desensitize employees to the ethical implications of their work. Financial incentives, tied to profit margins and market share, often overshadow patient well-being, leading to "moral injury" among healthcare workers who feel compelled to compromise their professional ethics. This systemic pressure can transform morally questionable conduct into routine business tasks, distancing employees from the human harm they cause.

7. Systemic Racism Exacerbates Health Disparities in Dialysis Care

Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death.

Dialysis deserts. Kidney failure disproportionately affects Black, brown, and Native American communities, which often exist as "dialysis deserts" – neighborhoods with limited access to healthy food and primary medical care, but an abundance of fast-food outlets and predatory businesses. These structural factors, combined with genetic predispositions and high rates of diabetes and hypertension, virtually guarantee widespread kidney disease in these populations.

Racial bias in care. Extensive research reveals significant racial disparities in dialysis care. African Americans, for instance, receive worse care than whites across multiple categories, including access to high-rated facilities, hospitalization rates, home dialysis options, and transplant waitlist placement. Even the estimated glomerular filtration rate (eGFR) algorithm, used to assess kidney function, has historically been incorrectly adjusted for race, artificially inflating eGFR in Black patients and potentially delaying necessary care or transplant eligibility.

Discriminatory practices. Accusations of "drug-seeking behavior" or "noncompliance" are disproportionately leveled against Black and brown patients, often serving as pretexts for involuntary discharge. These biases, rooted in historical and systemic racism within the medical system, lead to the stigmatization and punishment of patients of color. Such practices highlight how racial inequality is deeply embedded in the American healthcare landscape, turning a medical crisis into a further burden for marginalized communities.

8. Industry Consolidation Led to a "Fast Food Medicine" Model with Dire Outcomes

Any measure that could get worse pretty much got worse, after the big chains acquired independent facilities.

The "roll-up" phenomenon. Following the 1972 "Medicare for All" provision for dialysis, Wall Street recognized healthcare as a unique investment opportunity, backed by federal funds and immune to economic downturns. This spurred a rapid "roll-up" of the dialysis industry, where large firms acquired smaller, independent facilities. This consolidation, often occurring below the radar of antitrust authorities, created de facto monopolies in many local markets.

Erosion of quality. Economists studying this consolidation found that while it benefited executives and shareholders, it negatively impacted patient care. After large chains acquired independent facilities, death rates, hospitalization rates, and infection rates increased, while transplant rates fell. The "fast food medicine" model, prioritizing quick, standardized, low-cost treatments to maximize patient turnover, directly sacrificed quality of care for profitability.

Market imperfections. The American dialysis market is far from a free market. Patients face high travel costs, making proximity to a clinic crucial. They are "sticky," relying heavily on nephrologist referrals, which can be influenced by doctors' financial stakes in specific facilities. This lack of patient choice, combined with the duopolistic structure, allows large corporations to avoid genuine competition on quality, leading to consistently poorer outcomes for patients.

9. Patient Advocacy and Policy Shifts Offer Hope for Systemic Reform

For the first time, I’m beginning to feel that change might happen.

Grassroots movements. Despite the entrenched power of Big Dialysis, patient advocates and labor unions are driving significant efforts for reform. Organizations like Dialysis Advocates, led by Arlene Mullin, provide crucial support to patients facing involuntary discharge and other abuses. The SEIU-UHW union in California has launched highly public campaigns, including ballot initiatives and legal challenges, to demand safer conditions, better hygiene, and improved staffing ratios in clinics.

Political engagement. These advocacy groups have brought patients and workers to state capitols and Washington D.C., to educate lawmakers and lobby against industry-backed legislation that protects profit-maximizing practices. While facing massive spending from the dialysis lobby to defeat their initiatives, their persistent efforts have raised public awareness and garnered support from influential politicians, including California's governor and even a former HHS Secretary.

Promising developments. Recent years have seen encouraging policy shifts, including a presidential executive order calling for better early-stage kidney disease diagnosis, increased transplants, and more home dialysis. CMS is revising payment policies, and new bipartisan laws are before Congress to improve kidney care and support living donors. A civil rights lawsuit challenging "bazooka dialysis" in California, if successful, could set a precedent for broader industry reform.

10. Reclaiming the "Wisdom of the Kidney" for Societal Health and Compassion

We let people dialyze to live, rather than living to dialyze.

Patient-centered models. In contrast to the U.S., countries like Australia and New Zealand prioritize patient empowerment and quality of life, with widespread adoption of home dialysis. Patients are trained to manage their own treatments, fostering independence and better health outcomes. This approach, emphasizing flexibility and mutual trust between doctors and patients, allows individuals to live active, fulfilling lives, rather than being defined by their disease.

Societal homeostasis. The "wisdom of the kidney" serves as a powerful metaphor for societal health. Just as kidneys maintain the delicate balance of our internal environment, a healthy society requires equilibrium among its diverse elements—economic needs, political convictions, and moral values. When "toxins" like greed, fear, and inequality accumulate, they disrupt this balance, leading to systemic failures that manifest in various forms of human suffering.

A call to conscience. Listening to the voices of dialysis patients, who often embody resilience and profound wisdom despite their suffering, is crucial for America to regain its collective homeostasis. Their experiences highlight the urgent need to prioritize human compassion over profit, to ensure that healthcare is a fundamental right, not a commodity. By confronting the injustices in dialysis, America can begin to heal its own failing "kidneys" and reaffirm its commitment to a just and equitable society.