Profit-making in the treatment of chronic kidney disease: truth and consequences

Many have speculated that the quality of dialysis care differs for patients treated in for-profit and not-for-profit facilities. In 1999 we published a study that demonstrated poorer survival and lower rates of listing for renal transplant for patients in for-profit rather than not-for-profit, freestanding centers. While these findings generated substantial discussion, few have commented on their implications. In this article we first discuss potential sources of bias that could impact on the study's results and place the findings in context. We conclude that these disparities are likely to be real, as they are consistent with theorized differences between for-profit and not-for-profit health care organizations and with other evaluations of dialysis facility ownership. We then discuss several policy options for addressing the quality differences we identified. Reducing the outcome discrepancies will not be easy. Upon considering several policy alternatives, we conclude that a widespread effort to link processes of dialysis care to patient outcomes is best suited to reduce the quality differences between for-profit and not-for-profit dialysis units and improve outcomes in both types of facilities.