scientificamerican--2020-12-15--2020 Will Rival 2016 for Hottest Year on Record

With less than a month left in the year , 2020 is neck-and-neck with 2016 for the title of hottest year in recorded history .
It is virtually certain to be at least the second-hottest year .
Wherever it ultimately places in the record books , 2020 ’ s feverish heat came without the major El Niño event that boosted global temperatures to a new high four years ago—and thus this year provides an important marker of the power of the long-term warming trend driven by human activities that emit greenhouse gases .
“ Until we stop doing that , @ @ @ @ @ @ @ over and over again , ” says Gavin Schmidt , director of NASA ’ s Goddard Institute for Space Studies , which keeps the agency ’ s temperature records .
As of the end of November , 2020 is the second-warmest year on the books—a mere 0.02 degree Fahrenheit behind 2016 at the same point , according to new data released this week by the National Oceanic and Atmospheric Administration ( whose records go back 141 years ) .
By Schmidt ’ s calculations , it has a more than 90 percent chance @ @ @ @ @ @ @ NOAA gives it a 54 percent chance ; the agency gives it a 95 percent chance of being in the top two warmest years .
The variation between NASA and NOAA is partly because of the different ways each processes temperature data : NOAA does not extrapolate temperatures over the Arctic to make up for missing data there , and Schmidt says leaving that information out misses one of the fastest-warming spots on the globe .
One of 2020 ’ s notable hotspots has been Siberia , which has been covered by an @ @ @ @ @ @ @ maps .
The region has been exceptionally hot since the beginning of the year , contributing to this past January being the planet ’ s warmest on record .
At one point the Siberian town of Verkhoyansk reported 100.4 degrees F. If this figure is verified by the World Meteorological Organization , it would be the first time recorded temperatures above the Arctic Circle have surpassed 100 degrees F. But this hotspot is not the sole reason that 2020 is near the top of the charts .
Above-average temperatures have been prevalent over @ @ @ @ @ @ @ and Asia have had their hottest years to date , while South America , Oceania and the Caribbean have had their second-hottest .
Most of the world ’ s oceans have also been very warm , says Ahira Sánchez-Lugo , a climatologist at NOAA ’ s National Centers for Environmental Information .
And there are always hotspots somewhere on the globe in a given year—so the one in Siberia is not all that unusual , Schmidt says .
Last year , for example , the main hotspot was elsewhere in the Arctic , @ @ @ @ @ @ @ , Canada and Greenland .
But broad areas of warmth and more localized hotspots are both linked to the long-term warming trend .
“ It ’ s gotten to the point where these intense heat waves would not be possible in any reasonable amount of time in a non-human-perturbed climate , ” Schmidt says .
A recent analysis of the role of global warming in Siberia ’ s prolonged heat found that such extremes would happen around once every 80,000 years in the absence of anthropogenic warming .
These extremes are also happening @ @ @ @ @ @ @ the absence of climate change , Schmidt says .
Importantly , the run 2020 is making for the title of hottest year is happening without the major El Niño event that helped propel 2016 to the top of the rankings .
During an El Niño a band of warm ocean water covers the tropical Pacific Ocean , which can raise global temperatures .
“ When we have a big El Niño event , we do tend to have a record being broken , ” Schmidt says , adding that this factor is often @ @ @ @ @ @ @ by a large amount .
But an El Niño is not necessary to take the lead : both 2014 and 2015 became the then-hottest year without one .
“ We ’ ve broken the records pretty consistently , even in years where we didn ’ t have an El Niño , ” Schmidt says .
This fact also speaks to the way the inexorable rise in warming has been steadily elevating the baseline temperatures that events such as El Niño or heat waves add to .
Recently , even years with a La @ @ @ @ @ @ @ cooler , because colder ocean waters spread across the tropical Pacific ) are warmer than El Niño years of decades past .
To that point , 1998—the one 20th-century year that remains in NOAA ’ s top-10 warmest—did have a major El Niño .
It was a record-setting outlier at the time .
But because of global warming , the earth ’ s baseline temperature has shifted so much higher that 1998 is now being left in the dust ( 2016 , which had a similarly strong El Niño , was 0.63 degree @ @ @ @ @ @ @ 2020 ends up in the standings , it will be warm enough to knock 1998 out of NOAA ’ s top 10 .
When that happens , all of the 10 warmest years in their records will have occurred since 2005—and the top seven will have occurred since 2014—Sánchez-Lugo says .
That bunching of heat records in more recent years is , again , because of long-term warming , which is stacking the deck for ever more frequent records .
A 2017 analysis in Bulletin of the American Meteorological Society noted that between @ @ @ @ @ @ @ new records for the hottest year would happen about every eight to 11 years .
Since 1981 , they have been occurring about every three to four years .
So if 2020 takes the top slot , it will not be entirely unexpected—and will be yet another stark example of how far the earth ’ s climate has deviated from its natural course .
“ Everything that you see is conditioned on this long-term trend , ” Schmidt says .
“ I work for NASA , but it ’ s not rocket science @ @

The results are finally in: 2020 was one of the hottest years in recorded history, according to data released today by NASA and the National Oceanic and Atmospheric Administration. By NASA’s reckoning, it tied with 2016 for the hottest year in the books, while NOAA placed it in the number-two spot.
Regardless of its final placement, 2020’s feverish heat came without the major El Niño event that boosted global temperatures to a new high four years ago—and thus the year provides an important marker of the power of the long-term warming trend driven by human activities that emit greenhouse gases. “Until we stop doing that, we’re going to see this over and over again,” says Gavin Schmidt, director of NASA’s Goddard Institute for Space Studies, which keeps the agency’s temperature records.
In the final reckoning, 2020 was just 0.04 degree Fahrenheit behind 2016, according to NOAA (whose records go back 141 years). NASA found that 2020 was in a statistical tie with 2016. The variation between NASA and NOAA is partly because of the different ways each processes temperature data: NOAA does not extrapolate temperatures over the Arctic to make up for missing data there, and Schmidt says leaving that information out misses one of the fastest-warming spots on the globe.
One of 2020’s notable hotspots was Siberia, which was covered by an angry, deep-red blotch on global temperature maps. The region has been exceptionally hot since the beginning of that year, contributing to last January being the planet’s warmest on record. At one point the Siberian town of Verkhoyansk reported 100.4 degrees F. If this figure is verified by the World Meteorological Organization, it would be the first time recorded temperatures above the Arctic Circle have surpassed 100 degrees F.
Where temperatures have been warmer or cooler than average across the globe in 2020. Credit: NOAA
But this hotspot is not the sole reason that 2020 is at the top of the charts. Above-average temperatures were prevalent over large swaths of the globe. Europe and Asia had their hottest years on record, while South America and the Caribbean had their second-hottest, according to NOAA. The world’s oceans had their third warmest year. And there are always hotspots somewhere on the globe in a given year—so the one in Siberia is not all that unusual, Schmidt says. In 2019, for example, the main hotspot was elsewhere in the Arctic, in an area encompassing parts of Alaska, Canada and Greenland.
But broad areas of warmth and more localized hotspots are both linked to the long-term warming trend. “It’s gotten to the point where these intense heat waves would not be possible in any reasonable amount of time in a non-human-perturbed climate,” Schmidt says. A recent analysis of the role of global warming in Siberia’s prolonged heat found that such extremes would happen around once every 80,000 years in the absence of anthropogenic warming. These extremes are also happening over larger areas than they would in the absence of climate change, Schmidt says.
Importantly, 2020’s ranking at or near the top of the charts happened without the major El Niño event that helped propel 2016 to the top of the rankings. During an El Niño a band of warm ocean water covers the tropical Pacific Ocean, which can raise global temperatures. “When we have a big El Niño event, we do tend to have a record being broken,” Schmidt says, adding that this factor is often what causes the record to be broken by a large amount. But an El Niño is not necessary to take the lead: both 2014 and 2015 became the then-hottest year without one. “We’ve broken the records pretty consistently, even in years where we didn’t have an El Niño,” Schmidt says. This fact also speaks to the way the inexorable rise in warming has been steadily elevating the baseline temperatures that events such as El Niño or heat waves add to. Recently, even years with a La Niña event (which tend to be cooler, because colder ocean waters spread across the tropical Pacific) are warmer than El Niño years of decades past.
To that point, 1998—the one 20th-century year that had until recently remained in NOAA’s top 10 warmest—did have a major El Niño. It was a record-setting outlier at the time. But because of global warming, the earth’s baseline temperature has shifted so much higher that 1998 is now being left in the dust (2016, which had a similarly strong El Niño, was 0.63 degree F hotter). It has now officially been knocked out of NOAA’s top 10. All of the 10 warmest years in its records have occurred since 2005—and the top seven have occurred since 2014—says Ahira Sánchez-Lugo, a climatologist at NOAA’s National Centers for Environmental Information.
That bunching of heat records in more recent years is, again, because of long-term warming, which is stacking the deck for ever more frequent records. A 2017 analysis in Bulletin of the American Meteorological Society noted that between the late 19th century and 1980, new records for the hottest year would happen about every eight to 11 years. Since 1981, they have been occurring about every three to four years.
So 2020’s high ranking was not entirely unexpected—and is yet another stark example of how far the earth’s climate has deviated from its natural course. “Everything that you see is conditioned on this long-term trend,” Schmidt says. “I work for NASA, but it’s not rocket science.”


scientificamerican--2020-12-15--Giant U.S. Computer Security Breach Exploited Very Common Software

A hacking campaign has gained access to private information from a number of government and industry organizations , including the U.S .
Departments of Treasury , Commerce and Homeland Security .
The cyberattacks , which were first reported this past weekend , were carried out by compromising a software platform produced by a vendor called SolarWinds .
“ We are aware of a potential vulnerability which , if present , is currently believed to be related to updates which were released between March and June 2020 to our Orion monitoring products , ” Kevin Thompson , president and CEO of @ @ @ @ @ @ @ shared via e-mail .
“ We believe that this vulnerability is the result of a highly-sophisticated , targeted and manual supply chain attack by a nation state .
We are acting in close coordination with FireEye , the Federal Bureau of Investigation , the intelligence community , and other law enforcement to investigate these matters.
” Because thousands of clients rely on SolarWinds ’ products , experts expect more breaches to be revealed in the coming days .
Scientific American spoke with Ben Buchanan , a professor specializing in cybersecurity and statecraft at @ @ @ @ @ @ @ Service , about why so many organizations rely on such third-party software and how its compromise made them vulnerable to cyberattack .
[ An edited transcript of the interview follows . ]
How did the hackers manage to compromise so many groups ?
The heart of the issue here is that for big organizations , like government agencies or corporations , their computer networks are incredibly complex .
And they oftentimes turn to software to try to manage these computer networks : understand how the traffic flows , what devices are on their @ @ @ @ @ @ @ SolarWinds is an example of this kind of software that seems to be quite widely used throughout the government and industry .
But because it ’ s used to manage these networks , it has a position of privilege where it can see a lot of what goes on .
If you compromise SolarWinds , it then becomes possible to compromise the broader computer network .
Is that what happened here ?
That ’ s right .
We ’ re still learning more , but what it seems occurred is that hackers somehow @ @ @ @ @ @ @ of SolarWinds itself ; essentially they put a backdoor into SolarWinds that let them carry out malicious activity .
And the customers of SolarWinds downloaded this software update to their systems , not realizing it was in part malicious , at some point [ after ] March—and once they did this , they essentially gave the hackers an entry point into their network .
From there the hackers began doing things like harvesting passwords and other credentials to try to get further access to each of these networks that they [ had ] @ @ @ @ @ @ @ them by compromising SolarWinds .
With the passwords that they acquired , they almost certainly used that to get access to more computers and more accounts within the target organizations .
It seems their end goal was getting not just passwords , but also files and the like , and then pulling those pieces of information back out in an espionage operation .
I think it probably is too soon to say how extensive that espionage was , and it ’ s too soon to say how many of the possible victims actually @ @ @ @ @ @ @ says it was fewer than 18,000 organizations—which is not a reassuring number , because it ’ s big .
That seems to be the upper end on the reach of the espionage operation .
Thousands of organizations use SolarWinds , but how many more rely on other , similar software ?
I ’ m sure every large organization relies on something similar to manage a network that ’ s particularly complicated .
This kind of enterprise management is just part of running a modern , large organization—and the challenge right now is that @ @ @ @ @ @ @ s software .
In this case , one of the companies that they trusted turns out to have been breached .
I ’ m sure SolarWinds is not the only organization that 's in this position of trust .
And I ’ m sure any organization that sees itself used by so many high-profile targets is itself a target .
How do investigators figure out who is responsible for attacks like this ?
Just as police investigate a string of bank robberies by looking for a method of operations , or forensic evidence @ @ @ @ @ @ @ , you can do the same thing with hacking operations .
Investigators—often in the private sector , sometimes in the government—will look across a series of cases to build a pattern of operations for the hackers .
And they will cluster different patterns of operations to different groups .
And what the reporting indicates , in this case , is that the pattern of activity suggested this was the Russian SVR intelligence service that we ’ ve seen carry out very sophisticated hacking operations against the United States and worldwide targets before—never a @ @ @ @ @ @ @ espionage operations that hit high-value targets .
What do you predict is going to happen next ?
The next step is definitely going to be a very thorough investigation that is one of the most significant cyber investigations we ’ ve seen , just because the scope of this breach is so big .
We ’ re talking about potentially hundreds or thousands of organizations—likely hundreds I would say—that could have been compromised in this breach .
Once an agency as sophisticated as the SVR gets access to a network , they ’ @ @ @ @ @ @ @ So , remediating this breach is going to be difficult .
We ’ re going to start to realize , in the weeks to come , some degree of the information that was taken , some degree of who the victims are .
[ With ] every single one of those , I think it ’ s going to be another blow and raise the level of concern about this operation .
How can the cybersecurity community defend against this type of attack ?
This is a scenario , because the intrusions were @ @ @ @ @ @ @ s hard to come up with a list of easy fixes .
Because these are sophisticated adversaries , they compromised a system , SolarWinds , that was incredibly widely used and widely trusted .
They essentially exploited that trust to carry out their operations , and that is something that ’ s really hard to defend against .
This is not the same thing as just fixing a single software vulnerability and applying a patch—it ’ s a lot more difficult to combat this kind of threat .
This sheds some light on @ @ @ @ @ @ @ nations in cyberspace .
We spend a lot of time talking about things like deterrence , norms and signaling between nations .
But my view is that this kind of activity—competition , espionage , well below the threshold of conflict , what I call shaping the international environment to suit one ’ s ends—that ’ s par for the course in cybersecurity .
So , while this is certainly a high-water mark , the daily competition that leads to events like this is par for the course .
And I think we probably @ @ @ @ @ @ @ policy world thinking about the implications of that .
It ’ s pretty clear right now [ that ] the status quo , both in policy and in technology , does not let us deter this activity , and does not let us technically block this activity .

A hacking campaign has gained access to private information from a number of government and industry organizations, including the U.S. Departments of Treasury, Commerce and Homeland Security. The cyberattacks, which were first reported this past weekend, were carried out by compromising a software platform produced by a vendor called SolarWinds.
“We are aware of a potential vulnerability which, if present, is currently believed to be related to updates which were released between March and June 2020 to our Orion monitoring products,” Kevin Thompson, president and CEO of SolarWinds, explained in a prepared statement shared via e-mail. “We believe that this vulnerability is the result of a highly-sophisticated, targeted and manual supply chain attack by a nation state. We are acting in close coordination with FireEye, the Federal Bureau of Investigation, the intelligence community, and other law enforcement to investigate these matters.”
Because thousands of clients rely on SolarWinds’ products, experts expect more breaches to be revealed in the coming days. Scientific American spoke with Ben Buchanan, a professor specializing in cybersecurity and statecraft at Georgetown University’s School of Foreign Service, about why so many organizations rely on such third-party software and how its compromise made them vulnerable to cyberattack.
[An edited transcript of the interview follows.]
How did the hackers manage to compromise so many groups?
The heart of the issue here is that for big organizations, like government agencies or corporations, their computer networks are incredibly complex. And they oftentimes turn to software to try to manage these computer networks: understand how the traffic flows, what devices are on their network, how things are configured. SolarWinds is an example of this kind of software that seems to be quite widely used throughout the government and industry. But because it’s used to manage these networks, it has a position of privilege where it can see a lot of what goes on. If you compromise SolarWinds, it then becomes possible to compromise the broader computer network.
Is that what happened here?
That’s right. We’re still learning more, but what it seems occurred is that hackers somehow gained the ability to manipulate the code of SolarWinds itself; essentially they put a backdoor into SolarWinds that let them carry out malicious activity. And the customers of SolarWinds downloaded this software update to their systems, not realizing it was in part malicious, at some point [after] March—and once they did this, they essentially gave the hackers an entry point into their network. From there the hackers began doing things like harvesting passwords and other credentials to try to get further access to each of these networks that they [had] compromised with the initial toehold given to them by compromising SolarWinds.
With the passwords that they acquired, they almost certainly used that to get access to more computers and more accounts within the target organizations. It seems their end goal was getting not just passwords, but also files and the like, and then pulling those pieces of information back out in an espionage operation. I think it probably is too soon to say how extensive that espionage was, and it’s too soon to say how many of the possible victims actually were breached in this way. SolarWinds says it was fewer than 18,000 organizations—which is not a reassuring number, because it’s big. That seems to be the upper end on the reach of the espionage operation.
Thousands of organizations use SolarWinds, but how many more rely on other, similar software?
I’m sure every large organization relies on something similar to manage a network that’s particularly complicated. This kind of enterprise management is just part of running a modern, large organization—and the challenge right now is that these organizations have to trust somebody’s software. In this case, one of the companies that they trusted turns out to have been breached. I’m sure SolarWinds is not the only organization that's in this position of trust. And I’m sure any organization that sees itself used by so many high-profile targets is itself a target.
How do investigators figure out who is responsible for attacks like this?
Just as police investigate a string of bank robberies by looking for a method of operations, or forensic evidence that links one robbery to the next, you can do the same thing with hacking operations. Investigators—often in the private sector, sometimes in the government—will look across a series of cases to build a pattern of operations for the hackers. And they will cluster different patterns of operations to different groups. And what the reporting indicates, in this case, is that the pattern of activity suggested this was the Russian SVR intelligence service that we’ve seen carry out very sophisticated hacking operations against the United States and worldwide targets before—never a destructive attack, but always these intricate espionage operations that hit high-value targets.
What do you predict is going to happen next?
The next step is definitely going to be a very thorough investigation that is one of the most significant cyber investigations we’ve seen, just because the scope of this breach is so big. We’re talking about potentially hundreds or thousands of organizations—likely hundreds I would say—that could have been compromised in this breach. Once an agency as sophisticated as the SVR gets access to a network, they’re very hard to get out. So, remediating this breach is going to be difficult. We’re going to start to realize, in the weeks to come, some degree of the information that was taken, some degree of who the victims are. [With] every single one of those, I think it’s going to be another blow and raise the level of concern about this operation.
How can the cybersecurity community defend against this type of attack?
This is a scenario, because the intrusions were so well done, when it’s hard to come up with a list of easy fixes. Because these are sophisticated adversaries, they compromised a system, SolarWinds, that was incredibly widely used and widely trusted. They essentially exploited that trust to carry out their operations, and that is something that’s really hard to defend against. This is not the same thing as just fixing a single software vulnerability and applying a patch—it’s a lot more difficult to combat this kind of threat.
This sheds some light on just how fierce the competition is between nations in cyberspace. We spend a lot of time talking about things like deterrence, norms and signaling between nations. But my view is that this kind of activity—competition, espionage, well below the threshold of conflict, what I call shaping the international environment to suit one’s ends—that’s par for the course in cybersecurity. So, while this is certainly a high-water mark, the daily competition that leads to events like this is par for the course. And I think we probably need to spend more time in the policy world thinking about the implications of that. It’s pretty clear right now [that] the status quo, both in policy and in technology, does not let us deter this activity, and does not let us technically block this activity.


scientificamerican--2020-12-15--Should Your Kidney Doctor Have a Financial Stake in Dialysis?

When Jeffrey Berns first began practice as a nephrologist in the late 1980s , kidney disease in the U.S. was in the early stages of a stratospheric rise .
In 1972 , Congress had passed legislation that made anyone with end-stage renal disease , or ESRD — the current formal medical diagnosis for kidney failure — eligible for Medicare .
Unlike private insurance , which rarely covered dialysis at the time , Medicare did , and the nation was at the dawn of a dialysis demand boom .
The only question for the marketplace was : Who was going to @ @ @ @ @ @ @ The answer wasn ’ t immediately obvious .
People with ESRD present some of the most complex cases in all of medicine , says Berns .
They often have a variety of co-occurring conditions , from anemia to diabetes to heart failure , and this makes managing their care time-consuming — something that many doctors say isn ’ t adequately reimbursed in the Medicare fee for a basic appointment Independent and hospital-based dialysis clinics began popping up in the 1960s and 70s , but thanks to an aging population and rising rates of @ @ @ @ @ @ @ ESRD population grew so quickly that the dialysis industry couldn ’ t keep up .
Although the dialysis industry was incredibly lucrative , startup costs were , and still are , steep , according to Deepak Jasuja , a nephrologist with Columbus Regional Health outside Indianapolis .
What emerged was the joint venture , an entrepreneurial arrangement that lets two or more individuals share in the risks and benefits of a business .
In the case of kidney disease treatment , two key services were in play : the diagnosis and management of @ @ @ @ @ @ @ dialysis , by a nephrologist and the delivery of mechanical dialysis itself , where the filtering that would normally be done by the kidney is done by machine .
This series is a co-production between Undark and Scientific American and was supported by a reporting grant from the National Institute for Health Care Management Foundation .
It proved a winning solution , and in the decades since Berns entered the field , the number of dialysis clinics has exploded .
By 2008 , the average zip code in the U.S. had 1.2 dialysis @ @ @ @ @ @ @ as seven .
The problem , says Berns , is that no one outside the two big chains that own most dialysis clinics has any idea of how many are operated as joint ventures , and how that arrangement can influence medical decision making Berns — who before decamping in 1999 to the University of Pennsylvania and a career in academic medicine was briefly part of a practice in Virginia where other doctors had a joint venture arrangement — says that patients often don ’ t know that their doctors might have a @ @ @ @ @ @ @ which they are referred .
Among other important issues , Berns suggests , the arrangement leaves many nephrologists with a financial incentive to steer patients to their co-owned clinics for dialysis , even when other , perhaps even better or more appropriate interventions like medication and lifestyle changes are available .
And worst of all , Berns argues , most of his colleagues in the wider medical community seem largely unconcerned about the potential conflicts of interest “ If you really look at the corporation 's obligation to shareholders and you take that @ @ @ @ @ @ @ to patients seriously , I think they 're fundamentally incompatible , ” said Klemens Meyer , a nephrologist and director of dialysis services at Tufts Medical Center .
“ And I think that this is whitewashed over.
” Not everyone shares this sense of alarm .
The rise of joint ventures has helped greatly expand the number of dialysis clinics in the country , which has given patients more options and the ability to be treated closer to home .
This is a huge benefit to people who typically have to travel to @ @ @ @ @ @ @ or shine , says nephrologist Alvin Moss at West Virginia University .
( While Medicare announced a new program this fall that seeks to increase the number of patients using at-home dialysis , for now , the majority continue to receive treatment in a clinic . )
Of joint ventures , Moss doesn ’ t deny that the potential for conflicts of interest is real , but he says that with guidelines and institutional oversight these physicians can still put their patient ’ s interests ahead of their own .
But Berns is @ @ @ @ @ @ @ that he — alongside a small cadre of like-minded experts — has made it a mission to expose and address what he considers to be the inherent and too-often ignored conflicts that underpin the delivery of dialysis treatment in the United States .
Along the way — and using the federal Freedom of Information Act to obtain records on the more than 7,500 dialysis clinics in the U.S. — he has earned a reputation as a gadfly and the ire of many of his professional colleagues .
That ’ s fine , Berns @ @ @ @ @ @ @ be shed on an otherwise opaque marketplace .
“ People can study whether or not for-profit dialysis has different outcomes than not-for-profit dialysis because it 's public knowledge , ” he said .
“ But you ca n't do a study of joint venture because no one knows which ones are and aren ’ t. ” No sooner had the Seattle Artificial Kidney Center opened its doors on January 1 , 1962 than its anonymous seven-member admissions and policy committee faced an awesome decision .
Their task was to decide which of the @ @ @ @ @ @ @ failure patients would receive treatment on one of the center ’ s three new dialysis machines .
The contraptions were inefficient and it took an overnight stay for a single machine to filter toxins from the blood of a patient .
And despite being cobbled together from spare parts from nearby hospitals and a local soft serve ice cream machine manufacturer , they were still quite costly .
Of the first 30 patients referred to the committee , only 17 met the stringent pre-screening medical criteria .
The committee selected 10 of these @ @ @ @ @ @ @ died from kidney failure .
Even as late as the early 1980s , as kidney disease rates were mounting their historic climb , dialysis services could be hard to come by .
Moss , then a nephrologist in Morgantown , West Virginia , recalls many of his patients driving upwards of two hours each way to the closest clinic .
For the standard thrice-weekly regimen of treatments , travel was a huge burden on patients , Moss says — and that ’ s partly what helped drive the joint-venture model .
“ Before @ @ @ @ @ @ @ , “ nephrologists were getting involved in joint ventures to try and get dialysis centers more widely available.
” The arrangement is , in many respects , a natural and obvious one .
The intimate relationship between nephrology and dialysis , combined with the challenges of coordinating the complex medical needs of ESRD patients , means that nephrologists have a built-in incentive to open their own dialysis clinic , even independent of the fact that it can be highly profitable .
But while nephrologists have the medical expertise needed to care for patients @ @ @ @ @ @ @ from having business partners who know more about balancing the books and managing complex income streams .
A joint venture allows each contributor to play to their own strengths , explains certified financial planner Nick Hernandez , who specializes in advising physicians .
Joint ventures have become a mainstay in medicine for a variety of other reasons , says Hernandez .
Perhaps most importantly , a joint venture allows participants , who may include multiple physicians who might otherwise be competing against one another , to pool their resources to get a new @ @ @ @ @ @ @ in both the risks and the rewards .
It can take $ 3 million or more in startup costs to get a new clinic off the ground , an amount that would be shared among the joint venture participants , and if more cash is needed at any point , the participants share proportional responsibility in raising that capital .
And the ownership structure of joint ventures is flexible .
Investing more money at the outset means that person is taking on a greater risk , Hernandez says , but it also means @ @ @ @ @ @ @ of the rewards , whether it ’ s the clinic ’ s profits or payouts if the small startup clinic is bought out by a larger dialysis chain .
Physicians see additional rewards from joint venture dialysis clinics , since these facilities also provide a steady source of patient referrals for nephrologists , according to Jasuja .
In all , he said , “ it ’ s a big chunk of financial revenue that can potentially come from these sources.
” A July 2019 report from the research firm Marketdata estimates that the @ @ @ @ @ @ @ country today pull in more than $ 3 million in receipts annually on average , with an estimated net profit margin of 18 percent .
In a health care market where profit margins like this are increasingly rare , dialysis clinics can be attractive investment options for young nephrologists , explains Hernandez .
In the 1980s , when dialysis clinics were relatively rare and the need for such centers far outstripped their supply , Moss said that the possibility of sharing in the profits from treatment provided much-needed incentives for nephrologists to build @ @ @ @ @ @ @ so few downsides , ” he said .
The number of outpatient dialysis centers nearly doubled between 2001 and 2011 , but with the boom came a wave of consolidation , and today some 70 percent of all dialysis clinics in the U.S. are owned by just two firms : Denver-based DaVita , and Fresenius , which is headquartered in Bad Homburg , Germany .
Joint ventures have evolved with this vastly different dialysis landscape .
According to Hernandez , this arrangement helps mitigate some of the risk of opening an independent clinic @ @ @ @ @ @ @ still underserved by dialysis centers , Moss says the model continues to provide incentives for entrepreneurially-minded nephrologists to meet this need .
DaVita ’ s webpage on joint ventures and acquisitions showed that the number of joint venture clinics partly owned by the company has risen from 259 in 2008 to 671 in 2018 , equaling one-quarter of the chain ’ s 2,625 outpatient dialysis centers in the U.S. at the time .
The problem is that for many early career nephrologists , joint venture dialysis clinics are the only way they can @ @ @ @ @ @ @ a nephrologist at Lehigh Valley Hospital in Allentown , Pennsylvania .
Competition from hospitals and large nephrology group practices can make it all but impossible for young nephrologists to run a small , independent practice .
With six-figure medical school debt and facing a specialty choice with long hours and relatively low pay , owning a piece of a dialysis clinic is a lifeline , he says .
And it ’ s these benefits that DaVita emphasizes in its own promotional literature on the subject .
Of the six reasons it provides nephrologists @ @ @ @ @ @ @ one has to do with improving patient care .
The other five concern financial benefits for the investing physician .
As a joint venture participant during his early career , Berns knows all of this well .
Especially for young nephrologists , joint venture dialysis clinics can seem like the only viable path .
Large dialysis providers like DaVita and Fresenius are equally attached to this model , he says .
“ Dialysis facilities prefer that because the nephrologist has some skin in the game , ” Berns said .
“ And it @ @ @ @ @ @ @ a revenue stream that 's not directly related to seeing a patient.
” Because physicians have their own money on the line , they may have an additional incentive to see that the clinic provides good care so that it is profitable , acknowledged Berns .
It ’ s something that patients may also see as a plus , if they trust their doctor and their recommendations .
But Moss said that physicians do n't generally need a financial motivator to provide quality care , and acknowledged that these same financial incentives could @ @ @ @ @ @ @ patients towards their own clinic and away from options that might be more beneficial .
It ’ s a classic case of conflict of interest , says Matthew McCoy , a colleague of Berns ’ at Penn .
“ If you own a share in the facility , ” he said , “ there 's financial incentives to get patients there and keep them there.
” Berns began thinking about these potential conflicts several years ago when the University of Pennsylvania sought his advice about their hospital ’ s financial participation in an @ @ @ @ @ @ @ .
Pioneered by the Centers for Medicare and Medicaid Services , an ESCO is a partnership between dialysis clinics , physicians , and hospitals to innovate and improve the care of patients in kidney failure .
In his conversations with hospital executives , Berns outlined some of his ethical concerns about the hospital system entering a joint venture ESCO .
Even if the hospital didn ’ t deliberately steer patients towards receiving care at Penn ’ s own ESCO , employees could feel subconscious pressure to do that .
As he increasingly thought @ @ @ @ @ @ @ , Berns realized that physicians who co-owned dialysis clinics as part of a joint venture could also feel that pressure .
Even more problematic was the fact that doctors aren ’ t required to tell their patients about joint venture participation .
“ As employees of the dialysis facility , we 're having conversations with patients about whether or not they should continue dialysis , ” he said .
“ It made me sort of unsettled to think that an employee of a dialysis company that stands to benefit if that patient starts @ @ @ @ @ @ @ patient and not divulging that fact.
” That physicians should prioritize the interests of their patients above all else , including their own financial benefit , forms one of the central tenets of medicine .
But in reaction to reports of widespread Medicare and Medicaid abuse and fraud , in 1989 Congress enacted what came to be known as the Stark Law to prevent doctors from referring patients to other clinics in which they have a financial relationship .
Joint venture dialysis facilities take advantage of certain exceptions written into Stark Law rules @ @ @ @ @ @ @ , the Anti-Kickback Statute prohibits payments for patient referrals .
So when David Barbetta , an accountant with DaVita , noticed that the company was selling physicians shares in existing dialysis clinics at below-market rates and buying shares in new joint ventures at artificially inflated rates , he believed something shady was happening .
What Barbetta uncovered was DaVita giving kickbacks to nephrologists but disguising the payouts as profits from joint ventures .
So Barbetta filed a whistleblower lawsuit in 2009 , the proceedings of which were eventually unsealed in 2015 .
The @ @ @ @ @ @ @ executives about his concerns , they brushed him off .
He recalled one telling him not to “ give me any of that ethics nonsense.
” For Eric Havian and Jessica Moore , Barbetta ’ s attorneys , the case was relatively straightforward .
“ We immediately looked at it and said , you know , this is just a plain old kickback scheme , ” said Havian .
“ This is just a way for DaVita to put a lot of extra money in doctors ’ pockets in exchange for doctors referring @ @ @ @ @ @ @ the Department of Justice joined the suit and initiated an investigation into DaVita ’ s practices , the company agreed in October 2014 to pay $ 350 million to resolve the allegations that they paid illegal kickbacks , plus an additional $ 39 million to settle other claims .
( At the time the settlement agreement was announced the company said `` it is our belief there was no intentional wrongdoing . ''
) The American fee-for-service medical system is rife with potential for these types of kickbacks and conflicts , says Meyer @ @ @ @ @ @ @ s why , he said , “ if you have the stock market sucking away resources , you just have a mess left over to take care of the patient , even though the people on the ground at the bedside may all have the best intentions and be very , very devoted.
” Berns and McCoy also wanted to know how these joint ventures impacted patient care .
For years , the U.S. government has gathered reams of data on dialysis clinics , most of which is available through the United States @ @ @ @ @ @ @ didn ’ t include any information about which dialysis clinics were joint ventures , let alone the parties that owned them .
So Berns filed a request under the Freedom of Information Act in 2016 with the Centers for Medicare and Medicaid Services ( CMS ) .
Surely , he felt , they would be able to tell him whether a dialysis clinic was a joint venture , given the detailed information they collected about these facilities .
It took more than a year for Berns to get a response .
When he @ @ @ @ @ @ @ on every dialysis clinic ’ s joint venture status would only be a click of a mouse away .
But when Berns and McCoy pored over the files given to them by CMS , they found nothing about joint ventures .
“ That 's what we asked for and we did n't get , ” Berns said .
The pair realized that if CMS didn ’ t know which dialysis clinics were joint ventures , then patients didn ’ t know , either , and this raised its own ethical quandaries .
Over @ @ @ @ @ @ @ laws had been passed to allow patients to see whether their doctors had received money from pharmaceutical companies , but no such law existed about physicians disclosing their financial interests in dialysis clinics .
Berns , McCoy , and Penn bioethicist Aaron Glickman formally raised these concerns in a 2018 article in the New England Journal of Medicine .
They acknowledged that participating in a joint venture doesn ’ t mean a physician is inherently unethical , but they argued that patients have a right to know if their doctor has a financial @ @ @ @ @ @ @ This lack of transparency not only poses a major barrier for evidence-based health care policy , ” the authors wrote , “ but also deprives patients of critical information.
” Berns points to the New Jersey endoscopy clinic where he himself is a patient .
On the wall , he said , is a sign that clearly indicates who the owners are .
Dialysis clinics should have something similar , he said .
Both Meyer and Moss shared Berns and his colleagues ’ concerns , as did many other physicians who responded to @ @ @ @ @ @ @ Others , however , were less convinced .
In a blog post , nephrologist Terry Ketchersid , now an executive vice president at Fresenius , penned a detailed response , calling Berns and his colleagues naive and short-sighted .
“ [ T ] he authors are living in the dark ages , hanging on to vestiges of a transactional fee-for-service framework , and penning perspectives that might have been relevant when I was a teenager , ” he wrote .
“ I suspect it ’ s easy to sit in the confines of @ @ @ @ @ @ @ ethical , hardworking nephrologists who care for some of the sickest patients on the planet.
” Ketchersid declined to speak with Undark , but Berns regarded reactions like these to be an indicator that the issue was important and worth investigating further .
In a follow-up piece published earlier this year , Berns , Glickman , and UCLA nephrologist Eugene Lin argued that the lack of openness around joint ventures in nephrology was also interfering with the federal government ’ s ability to change how it pays providers for dialysis treatment .
With @ @ @ @ @ @ @ for patients , dialysis clinics have little incentive to change .
If CMS doesn ’ t account for these potential conflicts of interest when it tries to implement payment reforms for dialysis , it risks making the problem even worse , the trio argued .
“ It 's hard to simply eliminate these kinds of financial incentives with the snap of a finger , ” McCoy said .
Berns repeatedly emphasized that he wasn ’ t implying that financial conflicts of interest mean that a physician is unethical and in it just for @ @ @ @ @ @ @ all he knows , joint ventures could potentially improve patient care , but since the government doesn ’ t collect that data , he and other researchers have no way of knowing .
It ’ s something he has found frustrating to the point of maddening .
So Berns has begun the laborious task of contacting every clinic on the list he received from his FOIA request to determine whether it is a joint venture , so he and his colleagues can determine if and how this arrangement impacts factors like transplant rate @ @ @ @ @ @ @ No one can do studies on the question of physician ownership because the information is so hard to obtain , ” Berns said .
“ Patients and their families should have a right to know who has an ownership stake.
” UPDATE : An earlier version of this piece , along with a photo caption , imprecisely described Dr. Jeffrey Berns as having previously been a partner in a dialysis joint venture .
While Berns was part of a practice in Virginia where other doctors had a joint venture arrangement , he was @ @ @ @ @ @ @ the original version of this piece stated that DaVita had declined to comment on a whistleblower lawsuit that it settled in 2014 .
In fact , the company was not offered an opportunity to comment during the reporting process .
Undark has reached out to the company for input on the matter and will update this story when comment is provided .

When Jeffrey Berns first began practice as a nephrologist in the late 1980s, kidney disease in the U.S. was in the early stages of a stratospheric rise. In 1972, Congress had passed legislation that made anyone with end-stage renal disease, or ESRD — the current formal medical diagnosis for kidney failure — eligible for Medicare. Unlike private insurance, which rarely covered dialysis at the time, Medicare did, and the nation was at the dawn of a dialysis demand boom. The only question for the marketplace was: Who was going to step in to meet that demand.
The answer wasn’t immediately obvious. People with ESRD present some of the most complex cases in all of medicine, says Berns. They often have a variety of co-occurring conditions, from anemia to diabetes to heart failure, and this makes managing their care time-consuming — something that many doctors say isn’t adequately reimbursed in the Medicare fee for a basic appointment
Independent and hospital-based dialysis clinics began popping up in the 1960s and 70s, but thanks to an aging population and rising rates of diabetes and high blood pressure, the ESRD population grew so quickly that the dialysis industry couldn’t keep up. Although the dialysis industry was incredibly lucrative, startup costs were, and still are, steep, according to Deepak Jasuja, a nephrologist with Columbus Regional Health outside Indianapolis.
What emerged was the joint venture, an entrepreneurial arrangement that lets two or more individuals share in the risks and benefits of a business. In the case of kidney disease treatment, two key services were in play: the diagnosis and management of care for the patient, including prescribing dialysis, by a nephrologist and the delivery of mechanical dialysis itself, where the filtering that would normally be done by the kidney is done by machine.
This series is a co-production between Undark and Scientific American and was supported by a reporting grant from the National Institute for Health Care Management Foundation.
It proved a winning solution, and in the decades since Berns entered the field, the number of dialysis clinics has exploded. By 2008, the average zip code in the U.S. had 1.2 dialysis clinics, with some having as many as seven. The problem, says Berns, is that no one outside the two big chains that own most dialysis clinics has any idea of how many are operated as joint ventures, and how that arrangement can influence medical decision making
Berns — who before decamping in 1999 to the University of Pennsylvania and a career in academic medicine was briefly part of a practice in Virginia where other doctors had a joint venture arrangement — says that patients often don’t know that their doctors might have a financial stake in the dialysis clinics to which they are referred. Among other important issues, Berns suggests, the arrangement leaves many nephrologists with a financial incentive to steer patients to their co-owned clinics for dialysis, even when other, perhaps even better or more appropriate interventions like medication and lifestyle changes are available. And worst of all, Berns argues, most of his colleagues in the wider medical community seem largely unconcerned about the potential conflicts of interest
“If you really look at the corporation's obligation to shareholders and you take that seriously, and you take the obligation to patients seriously, I think they're fundamentally incompatible,” said Klemens Meyer, a nephrologist and director of dialysis services at Tufts Medical Center. “And I think that this is whitewashed over.”
Not everyone shares this sense of alarm. The rise of joint ventures has helped greatly expand the number of dialysis clinics in the country, which has given patients more options and the ability to be treated closer to home. This is a huge benefit to people who typically have to travel to treatment three times a week, rain or shine, says nephrologist Alvin Moss at West Virginia University. (While Medicare announced a new program this fall that seeks to increase the number of patients using at-home dialysis, for now, the majority continue to receive treatment in a clinic.)
Of joint ventures, Moss doesn’t deny that the potential for conflicts of interest is real, but he says that with guidelines and institutional oversight these physicians can still put their patient’s interests ahead of their own.
But Berns is convinced that the problem is significant enough that he — alongside a small cadre of like-minded experts — has made it a mission to expose and address what he considers to be the inherent and too-often ignored conflicts that underpin the delivery of dialysis treatment in the United States. Along the way — and using the federal Freedom of Information Act to obtain records on the more than 7,500 dialysis clinics in the U.S. — he has earned a reputation as a gadfly and the ire of many of his professional colleagues. That’s fine, Berns says, if a little light can be shed on an otherwise opaque marketplace.
“People can study whether or not for-profit dialysis has different outcomes than not-for-profit dialysis because it's public knowledge,” he said. “But you can't do a study of joint venture because no one knows which ones are and aren’t.”
No sooner had the Seattle Artificial Kidney Center opened its doors on January 1, 1962 than its anonymous seven-member admissions and policy committee faced an awesome decision. Their task was to decide which of the Pacific Northwest’s thousands of kidney failure patients would receive treatment on one of the center’s three new dialysis machines. The contraptions were inefficient and it took an overnight stay for a single machine to filter toxins from the blood of a patient. And despite being cobbled together from spare parts from nearby hospitals and a local soft serve ice cream machine manufacturer, they were still quite costly.
Of the first 30 patients referred to the committee, only 17 met the stringent pre-screening medical criteria. The committee selected 10 of these patients for dialysis; the other patients died from kidney failure.
Even as late as the early 1980s, as kidney disease rates were mounting their historic climb, dialysis services could be hard to come by. Moss, then a nephrologist in Morgantown, West Virginia, recalls many of his patients driving upwards of two hours each way to the closest clinic. For the standard thrice-weekly regimen of treatments, travel was a huge burden on patients, Moss says — and that’s partly what helped drive the joint-venture model. “Before they were everywhere,” Moss said, “nephrologists were getting involved in joint ventures to try and get dialysis centers more widely available.”
The arrangement is, in many respects, a natural and obvious one. The intimate relationship between nephrology and dialysis, combined with the challenges of coordinating the complex medical needs of ESRD patients, means that nephrologists have a built-in incentive to open their own dialysis clinic, even independent of the fact that it can be highly profitable.
But while nephrologists have the medical expertise needed to care for patients in kidney failure, they can benefit from having business partners who know more about balancing the books and managing complex income streams. A joint venture allows each contributor to play to their own strengths, explains Nick Hernandez, a consultant who specializes in advising physicians.
Joint ventures have become a mainstay in medicine for a variety of other reasons, says Hernandez. Perhaps most importantly, a joint venture allows participants, who may include multiple physicians who might otherwise be competing against one another, to pool their resources to get a new dialysis clinic up and running, sharing in both the risks and the rewards. It can take $3 million or more in startup costs to get a new clinic off the ground, an amount that would be shared among the joint venture participants, and if more cash is needed at any point, the participants share proportional responsibility in raising that capital.
And the ownership structure of joint ventures is flexible. Investing more money at the outset means that person is taking on a greater risk, Hernandez says, but it also means they will take in a larger share of the rewards, whether it’s the clinic’s profits or payouts if the small startup clinic is bought out by a larger dialysis chain. Physicians see additional rewards from joint venture dialysis clinics, since these facilities also provide a steady source of patient referrals for nephrologists, according to Jasuja. In all, he said, “it’s a big chunk of financial revenue that can potentially come from these sources.”
A July 2019 report from the research firm Marketdata estimates that the more than 7,500 dialysis clinics in the country today pull in more than $3 million in receipts annually on average, with an estimated net profit margin of 18 percent. In a health care market where profit margins like this are increasingly rare, dialysis clinics can be attractive investment options for young nephrologists, explains Hernandez.
In the 1980s, when dialysis clinics were relatively rare and the need for such centers far outstripped their supply, Moss said that the possibility of sharing in the profits from treatment provided much-needed incentives for nephrologists to build more dialysis centers. “There were so few downsides,” he said.
The number of outpatient dialysis centers nearly doubled between 2001 and 2011, but with the boom came a wave of consolidation, and today some 70 percent of all dialysis clinics in the U.S. are owned by just two firms: Denver-based DaVita, and Fresenius, which is headquartered in Bad Homburg, Germany.
Joint ventures have evolved with this vastly different dialysis landscape. According to Hernandez, this arrangement helps mitigate some of the risk of opening an independent clinic, and with parts of the country still underserved by dialysis centers, Moss says the model continues to provide incentives for entrepreneurially-minded nephrologists to meet this need. DaVita’s webpage on joint ventures and acquisitions showed that the number of joint venture clinics partly owned by the company has risen from 259 in 2008 to 671 in 2018, equaling one-quarter of the chain’s 2,625 outpatient dialysis centers in the U.S. at the time.
The problem is that for many early career nephrologists, joint venture dialysis clinics are the only way they can stay afloat, says Nelson Kopyt, a nephrologist at Lehigh Valley Hospital in Allentown, Pennsylvania. Competition from hospitals and large nephrology group practices can make it all but impossible for young nephrologists to run a small, independent practice. With six-figure medical school debt and facing a specialty choice with long hours and relatively low pay, owning a piece of a dialysis clinic is a lifeline, he says.
And it’s these benefits that DaVita emphasizes in its own promotional literature on the subject. Of the six reasons it provides nephrologists to consider a joint venture, only one has to do with improving patient care. The other five concern financial benefits for the investing physician.
As a joint venture participant during his early career, Berns knows all of this well. Especially for young nephrologists, joint venture dialysis clinics can seem like the only viable path. Large dialysis providers like DaVita and Fresenius are equally attached to this model, he says. “Dialysis facilities prefer that because the nephrologist has some skin in the game,” Berns said. “And it's a way for nephrologists to have a revenue stream that's not directly related to seeing a patient.”
Because physicians have their own money on the line, they may have an additional incentive to see that the clinic provides good care so that it is profitable, acknowledged Berns. It’s something that patients may also see as a plus, if they trust their doctor and their recommendations. But Moss said that physicians don't generally need a financial motivator to provide quality care, and acknowledged that these same financial incentives could also cause a physician to subconsciously steer patients towards their own clinic and away from options that might be more beneficial.
It’s a classic case of conflict of interest, says Matthew McCoy, a colleague of Berns’ at Penn. “If you own a share in the facility,” he said, “there's financial incentives to get patients there and keep them there.”
Berns began thinking about these potential conflicts several years ago when the University of Pennsylvania sought his advice about their hospital’s financial participation in an ESRD Seamless Care Organization (ESCO). Pioneered by the Centers for Medicare and Medicaid Services, an ESCO is a partnership between dialysis clinics, physicians, and hospitals to innovate and improve the care of patients in kidney failure. In his conversations with hospital executives, Berns outlined some of his ethical concerns about the hospital system entering a joint venture ESCO. Even if the hospital didn’t deliberately steer patients towards receiving care at Penn’s own ESCO, employees could feel subconscious pressure to do that.
As he increasingly thought about conflicts of interest and joint ventures, Berns realized that physicians who co-owned dialysis clinics as part of a joint venture could also feel that pressure. Even more problematic was the fact that doctors aren’t required to tell their patients about joint venture participation.
“As employees of the dialysis facility, we're having conversations with patients about whether or not they should continue dialysis,” he said. “It made me sort of unsettled to think that an employee of a dialysis company that stands to benefit if that patient starts dialysis is having that discussion with the patient and not divulging that fact.”
That physicians should prioritize the interests of their patients above all else, including their own financial benefit, forms one of the central tenets of medicine. But in reaction to reports of widespread Medicare and Medicaid abuse and fraud, in 1989 Congress enacted what came to be known as the Stark Law to prevent doctors from referring patients to other clinics in which they have a financial relationship.
Joint venture dialysis facilities take advantage of certain exceptions written into Stark Law rules, but a closely related federal law, the Anti-Kickback Statute prohibits payments for patient referrals. So when David Barbetta, an accountant with DaVita, noticed that the company was selling physicians shares in existing dialysis clinics at below-market rates and buying shares in new joint ventures at artificially inflated rates, he believed something shady was happening. What Barbetta uncovered was DaVita giving kickbacks to nephrologists but disguising the payouts as profits from joint ventures.
So Barbetta filed a whistleblower lawsuit in 2009, the proceedings of which were eventually unsealed in 2015. The lawsuit alleges that when Barbetta approached DaVita executives about his concerns, they brushed him off. He recalled one telling him not to “give me any of that ethics nonsense.” For Eric Havian and Jessica Moore, Barbetta’s attorneys, the case was relatively straightforward.
“We immediately looked at it and said, you know, this is just a plain old kickback scheme,” said Havian. “This is just a way for DaVita to put a lot of extra money in doctors’ pockets in exchange for doctors referring patients to their dialysis clinics.
After the Department of Justice joined the suit and initiated an investigation into DaVita’s practices, the company agreed in October 2014 to pay $350 million to resolve the allegations that they paid illegal kickbacks, plus an additional $39 million to settle other claims. (At the time the settlement agreement was announced the company said "it is our belief there was no intentional wrongdoing.")
The American fee-for-service medical system is rife with potential for these types of kickbacks and conflicts, says Meyer of Tufts Medical Center. It’s why, he said, “if you have the stock market sucking away resources, you just have a mess left over to take care of the patient, even though the people on the ground at the bedside may all have the best intentions and be very, very devoted.”
Berns and McCoy also wanted to know how these joint ventures impacted patient care.
For years, the U.S. government has gathered reams of data on dialysis clinics, most of which is available through the United States Renal Data System. But the database didn’t include any information about which dialysis clinics were joint ventures, let alone the parties that owned them. So Berns filed a request under the Freedom of Information Act in 2016 with the Centers for Medicare and Medicaid Services (CMS). Surely, he felt, they would be able to tell him whether a dialysis clinic was a joint venture, given the detailed information they collected about these facilities. It took more than a year for Berns to get a response. When he finally did, Berns assumed that data on every dialysis clinic’s joint venture status would only be a click of a mouse away. But when Berns and McCoy pored over the files given to them by CMS, they found nothing about joint ventures.
“That's what we asked for and we didn't get,” Berns said.
The pair realized that if CMS didn’t know which dialysis clinics were joint ventures, then patients didn’t know, either, and this raised its own ethical quandaries. Over the past decade, a variety of laws had been passed to allow patients to see whether their doctors had received money from pharmaceutical companies, but no such law existed about physicians disclosing their financial interests in dialysis clinics.
Berns, McCoy, and Penn bioethicist Aaron Glickman formally raised these concerns in a 2018 article in the New England Journal of Medicine. They acknowledged that participating in a joint venture doesn’t mean a physician is inherently unethical, but they argued that patients have a right to know if their doctor has a financial stake in their dialysis care. “This lack of transparency not only poses a major barrier for evidence-based health care policy,” the authors wrote, “but also deprives patients of critical information.”
Berns points to the New Jersey endoscopy clinic where he himself is a patient. On the wall, he said, is a sign that clearly indicates who the owners are. Dialysis clinics should have something similar, he said.
Both Meyer and Moss shared Berns and his colleagues’ concerns, as did many other physicians who responded to the NEJM article, Berns says. Others, however, were less convinced. In a blog post, nephrologist Terry Ketchersid, now an executive vice president at Fresenius, penned a detailed response, calling Berns and his colleagues naive and short-sighted. “[T]he authors are living in the dark ages, hanging on to vestiges of a transactional fee-for-service framework, and penning perspectives that might have been relevant when I was a teenager,” he wrote. “I suspect it’s easy to sit in the confines of this particular institution and cast stones at ethical, hardworking nephrologists who care for some of the sickest patients on the planet.”
Ketchersid declined to speak with Undark, but Berns regarded reactions like these to be an indicator that the issue was important and worth investigating further. In a follow-up piece published earlier this year, Berns, Glickman, and UCLA nephrologist Eugene Lin argued that the lack of openness around joint ventures in nephrology was also interfering with the federal government’s ability to change how it pays providers for dialysis treatment. With everyone profiting from the current arrangement except for patients, dialysis clinics have little incentive to change. If CMS doesn’t account for these potential conflicts of interest when it tries to implement payment reforms for dialysis, it risks making the problem even worse, the trio argued.
“It's hard to simply eliminate these kinds of financial incentives with the snap of a finger,” McCoy said.
Berns repeatedly emphasized that he wasn’t implying that financial conflicts of interest mean that a physician is unethical and in it just for the money. Berns says that for all he knows, joint ventures could potentially improve patient care, but since the government doesn’t collect that data, he and other researchers have no way of knowing. It’s something he has found frustrating to the point of maddening.
So Berns has begun the laborious task of contacting every clinic on the list he received from his FOIA request to determine whether it is a joint venture, so he and his colleagues can determine if and how this arrangement impacts factors like transplant rate, infection, and death.
“No one can do studies on the question of physician ownership because the information is so hard to obtain,” Berns said. “Patients and their families should have a right to know who has an ownership stake.”
UPDATE: An earlier version of this piece, along with a photo caption, imprecisely described Dr. Jeffrey Berns as having previously been a partner in a dialysis joint venture. While Berns was part of a practice in Virginia where the other doctors had a joint venture arrangement, he was not himself a partner. Separately, the original version of this piece stated that DaVita had declined to comment on a whistleblower lawsuit filed against it, but included a quote from a statement the company made at the time the suit was settled in 2014. In fact, DaVita was not offered an opportunity to comment during the reporting process. In follow-up phone calls and emails with DaVita post-publication, a spokesperson said the company had no comment beyond what was offered in the statement. The piece also originally described Nick Hernandez as a certified financial planner. He is a consultant.