Running head: POPULATION RISK

Population Risk
Patricia Adams
Ferris State University

POPULATION RISK

Population Risk
According to Campbell, Sanoff and Rosner (2010), the growth of undocumented
immigrants with end stage renal disease (ESRD) is expanding and decentralizing the United
States (U.S.) placing demands on the U.S. healthcare system and nephrology providers. Federal,
state and local policies influence the care of this vulnerable population. Balance of ethical and
quality care is vital to the promotion of health and reduction of healthcare costs in this vulnerable
population.
Vulnerable Populations
Many undocumented immigrants, some as children and others as adults, moved to the
U.S. in hope of a better life, to work and provide for their families. Harkness and DeMarco
(2016) define populations at risk as groups of people who have specific characteristics, or risk
factors, that increase the probability of developing health problems (p. 121). According to
Campbell, Sanoff, and Rosner (2010), 78% of undocumented immigrants in the U.S. are
Hispanic and 33% have a higher rate of advanced kidney disease when diagnosed. Access to
health care and benefits are restricted based on immigration status, ability to qualify for
insurance and to pay for healthcare. Fear of deportation, cost of care, lack of medical coverage,
and federal and state reimbursement policies contribute to circumvention of care (Campbell et
al., 2010).
Physicians alone do not share the burden of caring for this population of patients.
Hospital staff is required to care for them in an urgent, potentially life-threatening manner often
working late and dissolving the higher costs of care.

POPULATION RISK

According to Campbell et al. (2010):

The dialysis unit at Grady Hospital in Atlanta, GA, was a last resort of care for
many undocumented immigrants (31% of dialysis patients were undocumented
immigrants). Clinic staff had to work extra shifts and overtime to take care of the
growing patient load, and the dialysis unit was losing $3 million/y. Grady Hospital was
faced with the question: Should the hospital close down a dialysis unit that loses $3
million a year or should it continue the program that treats about 80100 patients a day?
Initially, Grady Hospital administrators decided to shut down the unit. However, a few
days later, they reversed that decision and kept the clinic open. Several Grady board
members believed that closing the clinic would lead to more emergency department
visits, longer stays in the intensive care unit, and more deaths. (p. 5)
Demographics
Local, state and federal policies for reimbursement of ESRD medical expenses vary from
state to state. According to Campbell et al. (2010):
The Illegal Immigration Reform and Immigrant Responsibility Act (Immigration
Act) of 1996 (Public Law 104-208) also had significance relating to provision of health
care for illegal immigrants. Because they could not provide even the minimal
documentation required, this Immigration Act effectively restricted access to health care
for illegal immigrants. These restrictions on care, through the requirement of specific
documents, also limit the ability of illegal immigrant patients to obtain care through other
government-supported systems and public assistance. (p. 3)

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Provision of care for undocumented immigrants without compensation puts nephrology

providers in a moral and ethical dilemma. According to Campbell et al. (2011), nephrologists
and dialysis providers may deny care to undocumented immigrants as a way to financially
uphold their own practice, yet as a health provider they have and ethical obligation to provide
equal care to those in need. States who do not cover dialysis treatment for undocumented
immigrants rely on taxpayers to fund the bill. The vulnerability continues for this population if
they are unable to obtain adequate healthcare where they live and work. Governed by state and
federal reimbursement policies, some providers are compelled to have undocumented
immigrants to move to states that have medical coverage for services, (Raghavan & Nuila, 2011).
This signifies that many individuals would not only have to leave their job for their health but
they may have to leave or relocate their families. Many undocumented immigrants have been
left with no other option than to rely on life threatening emergency room admission for life
saving treatments and yet, at times, are turned them away from emergency rooms because they
do not meet federal funding criteria (potassium level not critical or not in fluid overload)
(Campbell et al., 2010). That is to say, even though we know when these patients become ill,
we must wait until their lives are at risk before we provide dialysis (Raghavan & Nuila, 2011, p.
2184).
Health Concerns
As Sack (2011) points out dialysis patients all have specific needs depending on the
extent of their disease progression. Without proper medical treatment individuals with the ESRD
can die in as little as two weeks. This poses a serious threat to this vulnerable population.
Unable to pay for treatment and qualify for health insurance, undocumented citizens receive
suboptimal, more costly dialysis care. Lack of predialysis care can lead further disease

POPULATION RISK

progression and increased risk of morbidity and mortality. As pointed out by Campbell et al.
(2010), results of one cohort study indicated that differences in access to predialysis care
between undocumented immigrants and American citizens lead to later presentation in the course
of kidney failure and greater costs at the start of dialysis therapy (p. 4) see appendix. Many of
these patients utilize catheters instead of AV graft or fistulas, which increases the potential risk of
blood stream infection. They also require more blood transfusions and receive fewer treatments
per year (Campbell et al., 2010). There is significant morbidity and mortality that is caused by
the lack of appropriate dialysis access, volume and blood pressure management, anemia
management, and metabolic bone disease management (Campbell et al., 2010, p. 7). Physician
groups and dialysis providers who are not compensated for care are forced to provide
substandard care based on state and federal funding leading to poor outcomes, suboptimal health
and decreased life expectancy for undocumented immigrants. Collaborative efforts to revise
state and federal policies to include undocumented immigrants to have the same standard of care
will not only improve the health of this undeserved population but also will also decrease overall
costs of care and decrease the burden on emergency rooms and acute care facilities.
Collaborative efforts to change policies, combine resources and form agreements between care
facilities will help to eliminate this health disparity. As Sack (2011) points out, one hospital in
Atlanta formed an agreement with an outpatient hemodialysis facility and offered to pay a
reduced rate for treatment for undocumented immigrants. This not only gave these individuals
equal care but reduced the number and cost of emergent treatments. By receiving routine
scheduled thrice-weekly hemodialysis, this population would be able to actively participate in
secondary prevention instead of relying on tertiary care. Nephrology nurses can advocate for
change and promote health as an active member of the Nephrology Nursing Association or local

POPULATION RISK

kidney foundation. Nurses can also promote collaboration between physician groups, outpatient
centers and local hospitals to implement programs that provide optimal care.

POPULATION RISK

Conclusion
Emergent dialysis places burden on undocumented citizens and their families, nephrology
groups, emergency rooms, and acute care facilities. This type of treatment not only incurs higher
costs but it also puts patient lives at risk providing treatment for life-threatening conditions
instead of preventing them. Efforts to make policy changes at the local, state, and national level
will reduced healthcare costs, improve outcomes and decrease the biases faced by this vulnerable
population.

POPULATION RISK

References
Campbell, A., Sanoff, S., & Rosner, M. (2010). Care of the undocumented immigrant in the
United States with ESRD. American Journal of Kidney Diseases, 55(1), 181191.
Retrieved from http://www.medscape.com/viewarticle/715289_2
Harkness, G., DeMarco, R. (2016). Community and public health nursing: Evidence for
practice (2nd ed.). Philadelphia, PA: Wolters Kluwer.
Raghavan, R., & Nuila, R. (2011). Survivors Dialysis, immigration, and U.S. law. New
England Journal of Medicine, 364(23), 21832185.
http://doi.org/10.1056/NEJMp1101195
Sack, K. (2011, September 9). Deal reached on dialysis for immigrants - The New York Times.
The New York Times. Retrieved from
http://www.nytimes.com/2011/09/10/health/10grady.html?_r=0

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Appendix
Morbidity and Mortality Related to Lack of Predialysis Care
American Citizens

Undocumented

with ESRD

Immigrants with

Pre ESRD care

Glomerular Filtration Rate at Dialysis

61%
6.29

ESRD
27%
5.53

Initiation
Higher Mean Arterial Blood Pressure
Length of Hospital Stay
Cost of Hospital Admission

108.9
7.7
$11,396

119.9
10
$16,076