South Carolina's health department failed to inspect dozens of the state's dialysis clinics on time, even though nearly one-fifth of the facilities posted the federal government's worst mortality rating.

By the numbers

112 The number of federally certified facilities in South Carolina21 State dialysis clinics with death rates the government considers to be "worse than expected." The federal rating means that a clinic's mortality rate was worse than national death rates over a four-year period for patients with the same characteristics as the facility in question. It is among the measures the Centers for Medicare & Medicaid Services uses to determine whether a clinic meets federal standards for reimbursement.1,361 The number of patients treated in South Carolina dialysis clinics who died in 2009.1,198 The number of patients who would have been expected to die that year, adjusted for demographic factors and complicating medical conditions, according to the most recent state profile report compiled for the Centers for Medicare & Medicaid Services.

Of the state's 112 federally certified dialysis clinics, 21 have death rates the government considers to be "worse than expected," a Post and Courier review of national data showed.

Eleven of the 21 clinics with the worst death rates had not been inspected by the S.C. Department of Health and Environmental Control in more than four years. In all, 61 clinics have gone more than four years without having been inspected by the state, which requires each facility to be inspected at least every three years.

Nancy Maertens, director of DHEC's health licensing division, attributed the backlog to spending cuts. The division's five inspectors are responsible for inspections at a variety of facilities, including hospitals, nursing homes and residential treatment centers.

"Unfortunately, renal dialysis facilities are a lower priority," the department said in a statement.

There is no backlog in federally required inspections in South Carolina, according to the statement. The Centers for Medicaid & Medicare Services require one-third of a state's clinics to be inspected annually.

The 61-clinic state inspection backlog has built up because the division has not had a trained inspector for more than a year, Maertens said. A new inspector was trained in April and soon will begin "working through the backlog," she said.

State inspectors are responsible for ensuring that clinics are adequately staffed to handle their patient populations and have met safety codes, among other state regulations.

Only five staff positions currently are filled in the Division of Health Licensing, which considers itself fully staffed at seven, according to the statement. The division's budget has been cut by nearly 50 percent over the past two years, the statement said.

National trends

The "worse than expected" mortality rating appeared more frequently in South Carolina -- about 19 percent of clinics had the label -- than it did in neighboring states, according to federal data from 2006 through 2009 that was compiled by ProPublica, an independent investigative news organization.

In North Carolina, 18 of 173 clinics -- about 10 percent -- had the rating, according to the ProPublica data.

In Georgia, 19 of 269 -- about 7 percent -- rated worse than expected, according to the data.

The national data are adjusted for demographics and complicating medical conditions. For its analysis, The Post and Courier included only clinics whose "worse than expected" federal ratings were considered statistically significant.

DHEC officials said in a statement they "cannot speculate on the causes ... due to the many possible factors that may affect this medically fragile population."

Karen Delcioppo, a Charleston nephrology nurse and member of the state chapter of the American Nephrology Nurses Association, could not explain why South Carolina has more facilities with high death rates than Georgia and North Carolina.

"I just don't know. ... It's something the Renal Council has looked at," said Delcioppo, a member of the South Carolina Renal Dialysis Advisory Council, which advises the state on matters involving dialysis and kidney disease.

Two medical directors at Columbia-area Fresenius clinics, who serve with Delcioppo on the state council, said South Carolinians' willingness to comply with doctors' orders impacts morbidity rates.

"If they don't take their medications; if they don't go to treatments; if they come late and do two-and-a-half hours of dialysis instead of three or four -- all those influence mortality," said Koshy Abraham, medical director for the Fresenius Meadowlake clinic.

Howard Lifland, medical director of the Fresenius Newberry clinic, said poverty, education and diet all play a part in South Carolina's dialysis compliance and outcomes.

"Some of the responsibility has to be put on the patients," Abraham said. "It's not all on the doctors or the facility. If they don't keep up their end of the bargain, it doesn't matter how good I am."

The Southeastern Kidney Council, one of 18 groups contracted by the federal government nationwide to handle patient complaints, offered no explanation for the expected mortality rate differences.

"It's not something we have studied lately," spokeswoman Jenna Krisher said.

Dialysis comes at a huge cost to federal and state taxpayers because only a small fraction of the country's 400,000 dialysis patients are covered by private insurers, according to ProPublica.

Bill Peckham, a nationally-recognized patient advocate who writes a widely-read blog called "Dialysis from the sharp end of the needle," said Medicaid and Medicare reimbursement rates -- which vary by state -- contribute to differences in the quality of patient care.

In other words, states that have lower reimbursement rates per treatment give clinics fewer resources to pay for patient services, said Peckham, who lives in Washington, is involved in a variety of kidney research groups and has been on dialysis since 1988.

South Carolina's Medicaid reimbursement rates are lower than those in North Carolina and Georgia, according to figures each of those states provided to The Post and Courier.

In South Carolina, Medicaid reimburses at about $121 per treatment.

North Carolina reimburses clinics about $143 per treatment, according to the North Carolina Department of Health and Human Services.

Georgia reimburses about $124 per treatment, according to the Georgia Department of Community Health.

The three states have other differences too.

Medicare, the federal health insurance program for the elderly and some people with disabilities, reimburses 80 percent of a negotiated rate for dialysis, which varies by state. The remaining 20 percent must be covered by the patient. For people on Medicaid, the so-called payer of last resort, the state pays all or a portion of that amount.

In Georgia, the state Medicaid agency pays the full 20 percent, according to a spokeswoman for that agency.

North Carolina's Medicaid agency pays the full 20 percent for some patients, depending on their other assets, according to a spokesman for that department.

South Carolina Medicaid pays only 6 percent, according to S.C. Department of Health and Human Services spokesman Jeff Stensland. Sometimes the remaining 14 percent goes unpaid, he said.

The differences add up quickly and can leave clinics in states like South Carolina with vastly fewer overall resources, Peckham said. Reimbursement rates should concern all patients, regardless of their insurance, he said.

"In a dialysis unit, you're all getting the same thing, no matter if insurance through your employer is paying $1,000 per treatment or you're on Medicaid," he said. "If Medicaid reimburses less, clinics have less to work with."