Dialysis caregivers working at Fresenius Medical Care (FMC), DaVita, and Satellite Healthcare in California are organizing with SEIU-United Healthcare Workers West. The workers are organizing to improve their jobs, particularly to address a staffing crisis which has serious implications for both caregivers and patients, but which the companies refuse to resolve.

The increased risk to patients with end stage renal disease arising from worker burnout and understaffing are well documented in medical literature (see “Literature Review” below).  Deficits in the workforce have also drawn the attention of Wall Street investors and analysts who consistently note staffing shortages driving increased operating expenses and constraining capacity. Records obtained from the VHA, for example, document an unexpected closure of a Fresenius clinic in Oregon due to the lack of available staff.  These companies have the means to build a stronger workforce, but choose to pay their CEOs millions of dollars each year.

But we don’t have to rely on the companies and analysts to tell us that short staffing conditions at dialysis clinics and acute hospitals directly affect patients and caregivers alike. We know we have a crisis because frontline healthcare workers experience it every day.  Whether it’s an 18 hour work day, 6 day work weeks covering for sick coworkers, or frustration at not being able to give every patient 100%, we know that the impact is substantial.  

That is why we are asking policymakers to step in to address the structural changes needed to build a stronger dialysis workforce nationwide and meaningfully improve patient care.  

Dialysis workforce shortages and impacts

The US outpatient dialysis industry has faced a chronic shortage of nurses and patient care technicians for many years, a growing crisis which has been exacerbated by the pandemic. Surveys show that since 2020, staff have been especially impacted by higher workloads and experience greater levels of burnout and turnover intention.  

Publicly traded for-profit providers DaVita and Fresenius Medical Care (FMC), which together control nearly 75% of the US market, have acknowledged the staff shortages in quarterly releases. In 2022, FMC stated that the US labor market situation was affecting revenues and patient behavior. In 2023, DaVita, while acknowledging the impact of the COVID-19 pandemic on staffing and labor costs, reported:

Our business is labor intensive and our financial and operating results have been and continue to be sensitive to variations in labor-related costs and productivity. We have historically faced and expect to continue to face difficulties in hiring and retaining caregivers due in part to a nationwide shortage of clinical personnel….In addition, potential staffing shortages or disruptions, if material, could ultimately lead to the unplanned closures of certain centers or adversely impact clinical operations, and may otherwise have a material adverse impact on our ability to provide dialysis services or the cost of providing those services, among other things.

Combining risk resulting from burnout with the vulnerability of ESRD patients, the dangers to workers and patients alike are apparent. Aside from these impacts, staffing shortages have become a topic of interest to Wall Street investors as a driver of increased operating expenses and that COVID-19 burnout, low wages, aging workforce, lack of training, alternate career options, and more lucrative short-term contracts are spurring elevated turnover. DaVita and FMC have the means to address the root causes of the shortage: the companies generate billions in revenue each year and are consistently profitable enough to increase staffing. But rather than reinvest profits to build a stronger workforce, the companies pay out hundreds of millions to executives and shareholders.

Share buybacks and dividends

DaVita is a recurrent buyer of its own shares and over the last decade has reduced its total share count by 57%, showing its “strong commitment” to payouts for shareholders. From 2018 to 2022, DaVita spent over $7 Billion buying back its common stock. During this period, the company repurchased more shares than it earned in free cash flow, increasing both its debt load and exposure to rising interest rates. DaVita’s executive compensation is apparently structured to highly incentivize boosting its share price, as illustrated in CEO Javier Rodriguez’s $73.4 million pay package in 2020 that included $68 million in stock options.

FMC repurchased over $1 Billion of its common stock from 2017-2020; it has not repurchased shares since 2021. The company pays cash dividends each year, with an annual dividend amount of over $345 Million paid in 2022 and a total of over $2 Billion in dividends paid out from 2018-2022. 

Literature Review

Studies on staffing in healthcare conducted primarily in hospitals support the need for more staffing; there are many studies indicating that higher RN staffing, and hence lower patient-to-RN ratios, are associated with superior patient outcomes and fewer adverse patient events. Furthermore, there is existing literature from medical professionals, academics, and other experts on the impact of staffing levels in dialysis facilities to the quality of patient care and patient outcomes. One such study that examines dialysis clinic staffing and quality of care “reviews evidence related to inadequacies in clinic staffing and how they may be contributing to suboptimal care and outcomes” and concludes that dialysis clinic staffing levels is an issue of quality-of-care.

Additionally, another study notes, “Poor outcomes might also be attributable to lower levels of staffing in FP facilities . . . which notably affects ESRD patients who rely on their dialysis center as their primary health care provider . . .” An editorial also examines the current short supply of nephrology nursing services, exacerbated by the COVID-19 pandemic, and provides strategies [i.e. workplace safety, minimization of long hours, reduction of burnout] to address the shortage while highlighting the need to “ensure the vitality of the nurse workforce” in dialysis.  Findings from another study suggest that “…RN staffing levels have a significant impact on patient outcomes, operationalized in this study as adverse patient events in chronic hemodialysis units”.

Additionally, a published post in a newsletter by the National Kidney Foundation (NKF), provides clear examples of the challenges dialysis patients face because of staffing shortages such as delays in discharges from hospitals, placement at facilities far from patients’ home, delays in care and patient stress. Patient and worker safety is also potentially at risk due to staffing shortages in dialysis clinics; an article discussing infection control in the dialysis setting states that, “If the staff-to-patient ratio is so limited, fitting all of those steps [infection control protocols] between patients may be a challenge. Some of the required routines in each step may be shortchanged” potentially making the patient and worker more vulnerable to infections. The weight of this literature suggests that addressing staffing shortages in dialysis is crucial to protect workers and provide dialysis patients with quality care.

Workers on Short Staffing

Short staffing conditions at dialysis clinics and acute hospitals directly affect caregivers. Whether it’s an 18 hour work day, 6 day work weeks covering for sick coworkers, or frustration at not being able to give every patient 100%, the impact is substantial. 

Crystal Pivornik, a Registered Nurse working for Fresenius acutes, often works up to 18 hours a day: 

“I’ve worked at Fresenius for more than 20 years, and have been a dialysis nurse for more than 30. Never before have I seen conditions this bad. Acute dialysis nurses often work 18 hour days, with little time for rest between shifts because our patients will die without their treatment. With not enough time for meals or restroom breaks and chronically low pay, it has become impossible for us to hire the staff we need under these conditions.”

Yunis Cortez, a Registered Nurse working for Fresenius, describes the impact on her and her coworkers when a caregiver passed away: 

“My coworker died from cancer in January after years of working two jobs at Fresenius and DaVita six days a week just to make ends meet. Management didn’t hire her replacement for nearly ten months making the staffing crisis even worse in our clinic. We had to serve the role of both nurse and technician on the floor and we have done this for years, but not with so many patients—now we can treat as many as 15 dialysis patients at once and the smallest mistake could be fatal. Caregivers like me are left working 48 to 60 hours a week with little sleep in between shifts and it’s putting everyone at risk.”

The Impact of Short Staffing on Patient Care

As Cortez explains, there is great risk when clinics are so chronically understaffed. Her concerns are echoed by her colleagues at both clinics and acutes, and by patients and their families, who speak to the feelings of anxiety that patients suffer, as well as to the high stakes and potentially devastating consequences of short-staffing in dialysis. 

Mike Badilla, a Master Certified Clinical Hemodialysis Technician working for Satellite Healthcare describes the fear both patients and caregivers experience due to short staffing:  

“Satellite Healthcare has continued to squeeze every penny out of workers and our patients by understaffing our clinics and making it impossible to attract and retain experienced dialysis workers. Last month, we had a nurse caring for 24 patients at once for two consecutive days. If any one of those patients had an emergency or complication, it could be several minutes before they get the life-saving attention they need. What’s worse is that this even happens daily during our lunch breaks, when one nurse is caring for up to 24 patients because there is no relief. It’s not safe. It scares us and it scares our patients too.”

Carmen Cartagena, a former dialysis patient, shared her experience at a press conference in January, underlying the stakes for patients: 

“I’ve lost consciousness from blood pressure dropping, I’ve had my blood pressure so high one time that they feared I was going to have a stroke … When you’re on the machine, anything could happen … The dialysis team literally holds our lives in their hands. You can imagine the type of anxiety that it can cause.”

Conclusion: A proposal for federal requirements to reinvest in patient care

Approximately 89% of DaVita’s patients are covered under government-based programs, accounting for 67% of the company’s revenue from dialysis. Fresenius Medical Care, which operates globally, notes that approximately 25% of its revenues are from Medicare and Medicaid. With this duo of for-profit companies heavily dependent upon government programs for revenues but designed primarily for shareholder gain, policymakers can and should step in to address the structural changes needed to build a stronger dialysis workforce nationwide and meaningfully improve patient care.  

One such solution to promote investment in workers and patients is to require a minimum for spending on patient care and quality improvement activities similar to the Medical Loss Ratio rule of the Affordable Care Act. Under a rule requiring for-profit dialysis providers to spend 90% of revenues on patient care, both DaVita and FMC, which currently spend about 70-75% of revenues on healthcare services and products, would each invest an additional $2+ Billion per year. Additional funding allocated for purposes of worker recruitment, training and improved wages would provide benefits not only to workers, but also to the patients and companies as well by increasing employee retention, reducing the need for contract labor, and improving worker satisfaction and thereby quality of care.