Medicare's Chief M.D. Speaks About Dialysis

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Dialysis: An Experiment In Universal Health Care

TERRY GROSS, host:

This is FRESH AIR. I'm Terry Gross.

As Americans continue to debate health care reform, we're going to take a look
at a program funded by Medicare that some people consider the closest the U.S.
has come to socialized medicine.

In 1972, during the Nixon administration, Congress changed the Social Security
Act to give medical coverage to virtually anyone diagnosed with kidney failure,
coverage that included dialysis, a medical procedure which had only recently
been developed.

But this compassionate program has had some troubling health and financial
outcomes, according to a new article based on a year-long investigation by my
guest Robin Fields. She's a senior editor and former reporter for the
investigative journalism group ProPublica.

Her article was published on the ProPublica website and in the new edition of
The Atlantic magazine, which partnered with ProPublica on the project.

Robin Fields, welcome to FRESH AIR. Now, you say that this program of dialysis
that we have now is considered by some to be the closest we've ever come to
socialized medicine. In what way?

Ms. ROBIN FIELDS (Senior Editor, ProPublica): Well, actually, a doctor that was
speaking to an editor of mine once referred to it as socialized medicine for an
organ.

It gives comprehensive coverage, under Medicare, for all patients who suffer
from the same condition, which is kidney failure, and it not only covers their
dialysis and their transplants, it actually covers all of their medical costs
under a sort of a fixed reimbursement system that goes through Medicare.

GROSS: Now, you write that a program, this dialysis program, once envisioned as
a model for national health care, has evolved into a hulking monster. In what
sense has it become a hulking monster?

Ms. FIELDS: Well, for one thing, it's hugely larger than anyone could ever have
imagined. There are far more patients. There are far more complicated patients.
And the expense of it is wildly beyond the expectations of the architects of
the program.

GROSS: It's kind of amazing that this dialysis program became an entitlement
during the Nixon administration because right now, Republicans are so opposed
to health care reform. And, you know, Republican President Nixon signed this
entitlement. Congress passed it in 1972. What were some of the reasons behind
the passage of this entitlement?

Ms. FIELDS: I think that you hit on a really interesting point there, which is
that the mindset of the country was very different. And the expectations were
quite different, I think.

I think this kind of care was born in part just out of compassion. Here was a
chronic illness, and there was a treatment for it, but most people were not
getting it simply because of money. And I think that there was a moral
imperative there to step in and do something in the sense that it wasn't right
that in the wealthiest country on Earth that that was happening.

Immediately after the passage of the program, the country went into a fairly
deep recession, and it's possible had it gotten somehow pushed off the agenda
and delayed that they wouldn't have done it.

Also, the role of government and the role of government in health care really
has become a subject of very heated debate in the years that have followed,
whereas at that point in time, there was actually enormous consensus to do this
and to do this particular program, although obviously it was perceived as a
very small and localized program.

GROSS: One of the things this program was a reaction against is an actual life
and death committee at a medical center that was, what, screening who was and
who wasn't eligible for treatment with dialysis?

Ms. FIELDS: Yes, and was the subject of a hugely famous and very moving story
in Life magazine back in 1962. It was simply the model of rationing.

GROSS: Which is so controversial now, and when President Obama was trying to
pass health care reform, one of the arguments offered against it by some
Republicans was that this is going to end with death committees.

So what was this life and death committee? How did it function, and why was it
controversial in its time?

Ms. FIELDS: It was a committee made up of sort of regular people, not doctors.
And they were anonymous. And they would weigh each case and each person, and
they would consider not only their overall health and their ability to pay but
also things like their social worth.

And that's always a hugely controversial concept, the worth of a human life.
How can anyone hope to try to boil that down into a yes or no answer? And yet
also the source of the controversy was that once they made their decisions, the
people they didn't choose were basically going to die.

GROSS: So was somebody who was, you know, a middle-class professional more
likely to get the treatment than somebody who was poor?

Ms. FIELDS: I think they also were factoring in things like: Did they have
children? Were they active and important in their communities? What kind of
professions did they have? They were trying to add up, in some kind of non-
formula formula, the worth of a human being.

GROSS: And so this was considered, when the story was written about this in
Life magazine, this committee was considered to be a morally bad thing?

Ms. FIELDS: I think it was supposed to be a morally devastating and difficult
thing. They had no choice but to ration out these spots. It wasn't as though if
the committee didn't exist, those choices wouldn't have been made. They would
just have been made by doctors or by someone else. The tragedy was that they
had to be made at all.

GROSS: So you say that the Medicare program that covers people in kidney
failure, including dialysis, was never intended to cover such a large number of
patients. Would you just compare what the projections were to what the
actuality is now?

Ms. FIELDS: Sure. When the program started, the original estimates thought
there could be perhaps 35,000 patients. And then as that became clear that it
wasn't going to be true, they thought maybe 50,000 or maybe 90,000.

But what's really happened is that the patient community has continued to grow
because of conditions like diabetes and obesity becoming so much more common in
the larger health care system. And what we have right now is a situation where
more than 100,000 people start dialysis every year.

GROSS: And the connection between diabetes and kidney failure is?

Ms. FIELDS: Well, I would say it's a more than 40 percent of the dialysis
population has diabetes as an underlying condition. And that certainly wasn't
true at the beginning because really, when they were choosing patients before
the program, they didn't let people who had conditions like that get dialysis.
They didn't know if the treatment would work for them.

Once they had the entitlement, and they had sort of a financial structure which
allowed them to offer dialysis more broadly, people like that flowed into the
program, as well as older patients, as well as patients with hypertension and
other complicating conditions.

GROSS: So before we talk about why dialysis is so expensive and why it's so
difficult for patients, would you just explain what dialysis is?

Ms. FIELDS: Dialysis is a form of chronic care given to people who have kidney
failure where they're hooked up to a machine that effectively tries to do the
kinds of things that your kidney would naturally do. It cleanses the blood of
toxins and waste and excess fluid by taking it out of the body in a circuit,
sending it through a specialized filter and returning it to the body cleansed.

And people generally get in-center, what's called in-center hemodialysis is the
most common kind of dialysis. And that generally takes place in an outpatient
clinic, and patients come in three times a week is a typical regimen, and the
treatment averages three to four hours in length. And they sort of do it for as
long as they continue to be alive. And it's a pretty grueling way of life.

GROSS: So when the program covering care for people in kidney failure,
including dialysis, was created by Congress in 1972 and signed by President
Nixon, most of the dialysis centers were in hospitals. Now the overwhelming
majority, more than 80 percent of those dialysis centers, are private centers.
They're run by large corporations. Can you explain how and why that transition
happened from hospitals to corporate care?

Ms. FIELDS: I think it has very much to do with the payment policies of the
program from the get go. The payment policies were set at the beginning in some
ways to be quite generous and to draw providers in to create the desperately
needed access that the program was based on.

And the people who flowed in to create that access were mostly for-profit
providers. At first, it was kidney specialists, doctors who had practices, and
what would happen is they would start a clinic as an adjunct to their practice,
and often then they would be bought out by a chain of some kind.

And ultimately, as the payment policies evolved to somewhat suppress the price
of each treatment, what you found happening was that that sort of favored
providers who had economies of scale and could have purchasing power that
lowered their costs. And what - the product of that has been a vast changeover
in who provides the care.

Hospitals have sort of almost completely gotten out. They're really about eight
percent of the providers out there. And what's left is a provider community
almost, you know, 80 percent or more made up of for-profit providers, of which
the biggest are two big for-profit chains.

GROSS: So the two big companies that run most of the dialysis centers are
DaVida and Fresenius. Tell us something about those companies.

Ms. FIELDS: Well, both of them run more than 1,500 clinics apiece and have more
than 120,000 patients apiece. The closest provider to them in size has less
than 300 clinics. Both of them have made major acquisitions within the last
five to six years, which significantly boosted their proportion of the market.

I think that both of them have also worked very hard to evolve into one-stop
shopping for dialysis. They do all sorts of related businesses, and they have
labs. They have pharmacies. They have vascular access clinics, which is
something that dialysis patients use quite a lot.

And they've done a lot in terms of integrating the care that they offer, both
sort of horizontally and vertically, to make themselves more able to sort of
generate revenue, different revenue streams from the same patient community.
And I think that they've been solidly successful over the last several years in
doing that.

GROSS: Well, Fresenius, one of those two corporations, is actually the leading
maker of dialysis machines and supplies. So they're making a profit on the
technology, as well as on the patient care.

Ms. FIELDS: Actually, Fresenius started out as a manufacturer and became a big
service provider in the United States by acquiring the clinics of the original
dialysis chain, National Medical Care, back in the late '90s. So in a sense,
manufacturing is where they began.

GROSS: My guest is Robin Fields. Her new article investigating the benefits,
risks and costs of Medicare's lifesaving dialysis program is published in the
new edition of The Atlantic and on the ProPublica website. We'll talk more
after a break. This is FRESH AIR.

(Soundbite of music)

GROSS: If you're just joining us, my guest is Robin Fields. She's a former
reporter and now a senior editor at the investigative journalism group
ProPublica, and her new article on dialysis about lifesaving care at great risk
and cost has just been published in The Atlantic as a partnership between The
Atlantic and ProPublica.

Your article not only covers how we got to this point of spending about 6
percent of all Medicare money on treating people with kidney failure, including
dialysis treatment, you write about the conditions that you found and that
investigators have found at the dialysis centers that provide the treatment.

Can you just give us a sense of some of the problems that you found?

Ms. FIELDS: What we found in examining inspection reports as broadly and deeply
as we could was that many of the same patterns cropped up, and issues cropped
up, time and time again: unsafe and unsanitary conditions, prescription and
medical errors, issues of infection control and breaches in infection control,
issues that dealt with the amount of staffing, the training of staff and the
supervision of staff.

I would emphasize this isn't all clinics. Some clinics do a great job under
very difficult circumstances. But what we found was, not only looking at
inspections but in interviewing people broadly, was that some clinics are
operating in a way that seems to ratchet-up risks and that reflected some of
the frustrations voiced by patients and doctors and other practitioners alike
about one-size-fits-all care that didn't really give patients the best of the
medicine that's available or the best of the treatment options that are
available.

GROSS: Now, when you say unsanitary conditions, you describe clinics in which
there's blood in the seams of the chair, blood splattered on the ceilings,
blood on the floor. How does the blood end up there? What is it about the
procedure that there would be blood on the ceiling?

Ms. FIELDS: Well, obviously, the very essence of dialysis is moving blood
through the patients, from the patient to the machine and back into the
patient. So there's constant access to the patient's bloodstream.

They start the treatment by, you know, inserting needles into the patient's
access points. It is intrinsically a treatment that exposes patients to
bleeding.

But those kinds of conditions are not viewed as acceptable by the inspection
system and pose infection risks and other types of risk to patients if they are
allowed to exist.

GROSS: Now you mentioned staffing cutbacks. I mean, what that boils down to at
some of these centers is that care that used to be done by nurses is now being
done by unlicensed, unlicensed – who?

Ms. FIELDS: Technicians, although eventually they have to get certified. It's
true that staffing at dialysis clinics changed drastically. Those changes began
in the '80s, with price reductions, and have become sort of the norm.

Some people view this as a natural progression in that some of the processes of
dialysis have become simpler, the technology of the machines has become more
advanced, and there's a sense that on the one hand, you might not need a
skilled workforce, and on the other hand, with our nursing shortage, that a
more skilled workforce might be unrealistic.

But at the same time, there is no doubt that the kinds of tasks that are done
day-in, day-out at dialysis clinics are now done mostly by technicians who are
supervised by nurses.

GROSS: So if most of the employees are techs, technicians, what do the
regulations say about how many doctors and nurses have to be present at the
facility where dialysis is being performed?

Ms. FIELDS: It is required for clinics to have a medical director who is a
doctor, but they are typically not on-site at all times during treatment.
Usually, doctors come through on rounds, and there must be at least one
registered nurse while patients are being treated who is a treating nurse.
Those are the requirements in terms of the licensed staff.

Technicians must be certified within 18 months of being hired through a
recognized state or national program. But they can start with a high school
degree and having passed an in-house course.

There are no staffing ratios that are employed federally. Some states have some
requirements in this regard, but most states don't.

GROSS: Right now, an ongoing debate about health care reform and what should be
reimbursed or shouldn't be reimbursed, what kind of incentives there should be
for cost-cutting - so what are some of the big debates that have happened since
1972, when this kidney failure and dialysis program went into effect, about
what Medicare should cover and what it shouldn't and what kind of
qualifications, so to speak, patients should have in order to be covered?

Ms. FIELDS: I think that there's been a real resistance to creating any kind of
conditions on patients getting into – being eligible for this program.

The basic diagnosis of kidney failure has sort of been it. And I think as a
program created to end rationing, there's a great sensitivity on not creating
conditions that might rule out patients who are of a certain age or had certain
other types of complications.

Obviously, that's sort of almost a third rail for a program that was created to
end those sorts of decisions.

In terms of what's covered and what's not covered in payment policy, from the
start, the way that dialysis has been paid for is by the treatment. There's
been a base rate for each treatment. Originally, it was about $138, and it's
never been, unlike most of Medicare, tied to inflation, which has been a big
complaint and issue among providers.

In the '80s, after initial sets of audits found that providers were – that
certain providers especially were doing quite well off of the public program,
there was a sort of a big debate that evolved over how much profit was seemly
off of a public program and also how could you control how much of the money
you were spending on a dialysis treatment went to care versus went into the
pocket of the provider.

And this has been a source of tension for the program from the very beginning
and, as you point out, runs through a lot of the conversations that are being
had about health care.

GROSS: Robin Fields is a senior editor at the investigative journalism
organization ProPublica. Her new investigation into the dialysis industry is a
joint project of ProPublica and The Atlantic magazine. We'll talk more about
dialysis and the Medicare program funding it in the second half of the show.
I'm Terry Gross, and this is FRESH AIR.

(Soundbite of music)

TERRY GROSS, host:

This is FRESH AIR. I’m Terry Gross, back with Robin Fields. She is a senior
editor and former reporter for the investigative journalism organization
ProPublica.

We're talking about her year-long investigation into the quality of care at
dialysis centers. She also examines the Medicare program that funds dialysis
for patients with kidney failure and oversees the dialysis clinics. She
describes this Medicare program as the nation's most ambitious experiment in
universal health care. It was passed by Congress in 1972 during the Nixon
administration. Fields' article is published in the new edition of The Atlantic
magazine and on the ProPublica website.

You write that the government created a perverse incentive by allowing dialysis
clinics to bill Medicare separately for certain medications and then
reimbursing the centers at a markup over what they paid the drug makers for
those medications. And you write that dialysis actually became the loss leader.
A lot of these clinics were really making their profits off of drugs, and then
the question became did the patients really need those drugs or were the drugs
being prescribed for profit-making reasons? What did you find?

Ms. FIELDS: Yes. There was a huge debate over this several years ago, and a
great concern that drugs were being overused, in part because they were driving
profits and there were studies done that found in some cases that for-profit
operators tended to use larger doses and more injectable drugs than were used
at nonprofit centers. So, yes, this became a huge concern in the sense that it
was distorting the care. That by structuring the payment system this way you
were compelling, almost, people to behave in certain ways for economic reasons
that they wouldn't otherwise behave.

GROSS: So you write in your article that when compared to other countries, the
costs are higher in the United States for dialysis and kidney care treatment.
However, the outcomes are lower when compared to, or the outcomes are worse
when compared to other countries. Is there an explanation for that?

Ms. FIELDS: There are several. Part of it is that I think that our patient
population is different in certain ways than some of theirs. Our patients are
more inclined to have things like diabetes, heart disease. So we may have a
more difficult patient population. That could explain some of the differences.

But some of the differences clearly have to do with practices, including the
kinds of practices that are a function of having a less integrated health care
system and having patients come in with poor vascular access and poor overall
health in crisis conditions. And then some people would certainly say that the
general way that our clinics function is fundamentally different in certain
ways than the way clinics function in other countries. Treatments tend to be a
bit shorter. That's been linked to lower life expectancy and things like that.

GROSS: And what kind of profits are the two main corporations who run the
dialysis centers making?

Ms. FIELDS: They’ve been consistently profitable. They make about $2 billion
plus in operating profits per year. It's...

GROSS: Each makes two billion?

Ms. FIELDS: No, no, no, no. Collectively they make about $2 billion in
operating profits a year. They would certainly say that much of their profit
margin comes from the small percent of patients who are privately insured. It's
pretty clear that the two big chains are doing better financially than other
providers are and have significantly more latitude in terms of their margins
than smaller providers, who, many of whom are really struggling.

GROSS: Are there arguments on both ends here, one saying so much of the
government money is going to big profits for these corporations? And the other
side are the argument going, if it wasn't for these big corporations who would
be providing the care, because it's hard to manage that and not lose money, and
they're able to do it because they're doing it in bulk?

Ms. FIELDS: I think you put that very, very accurately. I think there's always
been an argument about how much profit is seemingly off of this area of care.
And I don't know that there's an answer to that - a right answer, anyway. I
mean, and even nonprofit providers have to be somewhat concerned with finances
because they need to, you know, pay their workers and keep the lights on. So it
isn't as if money comes entirely out of the equation when it comes to nonprofit
providers. But you're quite right when you say that we rely utterly on for-
profit providers at this point, and particularly, the big chains to provide the
access of care that is at the center of the system.

GROSS: Are there two tiers of systems right now for dialysis; one for people
who can't - who don't have their own insurance and who can't afford better care
and another for people who have private insurance and can afford better care?

Ms. FIELDS: No. I think that that's not really how the system breaks up. I
think that where there seem to be different tiers, if you will, of care is
mostly between patients who are extremely active and empowered and involved in
their care and more likely to try things that are considered quote/unquote
"alternative therapies" such as home dialysis or peritoneal dialysis, where the
patient takes on more independence and responsibility for their own care and
those types of care versus in-center tend to be - tend to yield better
outcomes, versus patients who sort of are more passive and go into the system
of in-center care, or for various reasons are not suited for those types of
alternative therapies.

GROSS: Robin Fields, thanks so much for talking with us.

Ms. FIELDS: Thanks for having me.

GROSS: Robin Fields is a senior editor and former reporter for the
investigative journalism organization ProPublica. Her investigation into the
cost and the quality of care at dialysis centers is a joint project of
ProPublica and The Atlantic magazine.
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Medicare's Chief MD Speaks About Dialysis

TERRY GROSS, host:

After talking with journalists Robin Fields about her investigation into the
quality of care at dialysis centers and the cost of treatment, we called Dr.
Barry Straube. He's the chief medical officer of the Centers for Medicare and
Medicaid Services and director of the Office of Clinical Standards and Quality
for Medicare and Medicaid.

Medicare pays for the dialysis and related drugs for patients with kidney
failure and enforces quality standards at dialysis centers. Robin Fields
describes this program as the nation's most ambitious experiment in universal
health care.

Dr. Straube, welcome to FRESH AIR. So let me just recap something that Robin
Fields says in her article. She says that although some clinics are orderly and
expert, others are run like factories. At some clinics blood is encrusted in
the folds of patients treatment chairs or spattered on the walls, floors or
ceiling tiles. Hundreds of clinics have been cited for infection control
breaches that expose patients to hepatitis, staph, TB, and HIV. And she says
clinics are supposed to be inspected once every three years on average, but as
October, almost one in 10 hadn't had a top to bottom check in at least five
years.

What's your assessment of the inspection problem?

Dr. BARRY STRAUBE (Chief medical officer, Centers for Medicare and Medicaid
Services): Terry, thank you very much for having me on the program today. I
think my initial reaction, and I have just skimmed the article, so I haven't
been able to analyze in depth. There definitely is truth in the fact that CMS
in its regulatory role overseeing the quality of care in dialysis facilities
has not been able to perform as many surveys and therefore, perform that type
oversight as well as it might like to have.

We are hindered by funding that comes from Congress in order to perform
regulatory oversight visits for all of the 17 different provider sites that CMS
is charged with regulating and overseeing the quality of care. And the funding
that is provided to the agency on one hand, is not insufficient to be able to
meet the statutory requirements in terms of frequency and fairness of those
site visits.

This is further complicated by the fact that several years ago, many on the
Hill felt that we needed to pay more attention to nursing homes than the other
types of facilities, including dialysis units. So we were instructed and had to
focus with annual visits to all nursing homes at the expense of other
facilities and dialysis facilities were, in fact, put on a lower priority track
because of that sentiment from the Hill and the funding needs. So we have been
not able to perform the oversight functions as frequently or as thoroughly as
we might like to.

GROSS: Do you agree with Robin Fields' assessments of the sanitary problems
and, you know, infection problems at many of these dialysis clinics?

Dr. STRAUBE: I believe that Robin's article, although pointing up some very
important issues that this agency and the Department of Health and Human
Services is aware of and trying its best to fix, that it overstates
significantly the degree of the problem out in the real world. It makes it
sound like any dialysis unit that a patient would walk into is subject to these
problems and that's simply not true. The vast, vast majority of the units are
not as described in the several examples, which are completely true examples
but not illustrative of most dialysis units.

I think my main quibble with the article is that it sounds as though one would
not want to have dialysis in the United States. This is a life-saving treatment
that the vast majority of people are being treated very well in very clean
facilities that hopefully make very few mistakes. And the examples there are
not indicative of most dialysis units.

GROSS: One of Robin Fields' criticisms in her investigative article about
dialysis centers is that they're largely run by tax technicians and that the
centers are legally required to have at least one nurse on the premises, and a
doctor has to serve as medical director, but the doctor doesn't have to be on
the premises all the time. So if something goes wrong, if there’s a medical
emergency, she says there isn't necessarily going to be the medical staff to
take care of it.

Dr. STRAUBE: Well, I think that over time there has been a tendency to using
fewer number of nurses and also using more technicians. This is not necessarily
a compromise in the quality of care, because the technicians are extremely
well-trained and the services that need to be performed for most aspects of the
dialysis treatment are quite routine and certainly within the competence and
skill set of a well-trained technician.

The fact that there are registered nurses on site, they also are well-trained
in terms of emergency interventions, et cetera. Historically, there have not
been doctors on-site full-time in any dialysis units for the most part. There
may be exceptions where hospital-based units and others may have had an on-site
medical physician. But generally, since the inception of the program, that has
not been done, so I think the absence of an M.D. does not necessarily
compromise the quality of care in the acute setting also.

GROSS: So I know that some of the payment system is about to change, but Robin
Fields in her article about dialysis centers, writes that until now the payment
system had a couple of perverse incentives. For example, the government has
allowed clinics to bill Medicare separately for certain medications,
reimbursing them at a markup over what they paid the drug makers. So she said,
the doctors at clinics started prescribing more drugs for problems like anemia
and dialysis ended up, becoming like the loss leader that got patients in the
door so that the clinics could sell drugs at a markup. So that's going to be
changed as of next year.

But I'm wondering what you've learned about incentives and pricing that, you
know, lessons learned from what you've witnessed.

Dr. STRAUBE: I think, Terry, we've learned, across the Medicare program that
the fee-for-service system provides perverse incentives. We, under fee-for-
service, pay the more people do something or the more drug or service they
provide, so that the agency for all payment systems is starting to revise those
systems to incentivize higher quality care and to try to make the process more
efficient.

GROSS: How is it going to be changed in terms of the dialysis centers?

Dr. STRAUBE: Again, as you describe before, we were paying a base fee for the
standard traditional dialysis services. But over the years, additional very
expensive drugs were added to the treatment regiment and these were paid for,
separately, and with a fairly significant profit margin, if you will. Now we're
going to take all of the services and all of the drugs, bundle it into a so-
call bundle payment so they'll be one payment that we determine is a reasonable
amount of money or an average dialysis facility, be able to provide good care,
and it will be up to the dialysis facilities to keep within that budget and
provide care for that amount of money or less. And they won't be able to over-
prescribed drugs or over-prescribed treatments because they won't be paid for
those like before.

GROSS: Is there a danger that they are going to under prescribe drugs because
they'll save money that way, since there is just a standard fee that they're
getting, no matter what the treatment is?

Dr. STRAUBE: Yes. There's definitely that and we're very concerned about that.
So that in devising the bundle payment system that I described, we have a
monitoring metrics that would be looking for under prescription of either drugs
and/or underutilization of the dialysis services, such as using too short a
dialysis time. We'll be monitoring for that and when we identify divergence for
either underutilization or other quality of care concerns we will be taking
investigative undertakings to see what's going on.

In addition, we are charged in 2012 with starting an end-stage renal disease
quality improvement or quality incentive program, where we give - we are
actually going to be able to reduce up to two percent of the dialysis units
reimbursement, based on whether or not they provide certain services to meet
certain quality metrics. And among those are a number of metrics that we’ve
proposed in the first year, that in fact look at situations where they might
under prescribe. So it's looking at anemia, management, which is largely
dependent on a very expensive drug called Epogen, and we're also going to be
looking at dialysis adequacy measures, so that if they're not dialyzing people
on enough period of time, that would show up on those measures. And if they
don't meet the prescribe metrics we will be withholding some of their payment
as a penalty.

GROSS: Robin Fields in her article says that we pay more per dialysis patient
in America than in other Western countries - in other industrialized countries.
And yet, our mortality rate for patients on dialysis is higher. How do you
explain that?

Dr. STRAUBE: Well, I think that's consistent with the fact that for all medical
services in the United States we pay far more per capita than other developed
countries in the health care world. And I think that's just indicative, that in
spite of efforts for the last decade to try to provide medicine and health care
more efficiently, we're still haven't succeeded. There's still a tremendous
amount of waste in the system where services that are not necessary are being
provided. Services that are more costly than others of equal benefit are being
provided, and any number of other reasons. So this is consistent with the
entire U.S. health care system.

I think, again, our payment reform proposal - well, the bundle payment reform
that we're implementing January 1st is going to go a long way towards
addressing that issue, because providers will now have a very strong incentive
to look at what they're providing and not spend money endlessly but, in fact,
to look at their expenditures and only give care that is absolutely necessary,
while avoiding negative effects and worsening care in doing so. So they are
going to have to walk that tightrope and that balance.

GROSS: Dr. Straube, thank you so much for talking with us.

Dr. STRAUBE: You’re quite welcome and thank you for having us on your show.

GROSS: Dr. Barry Straube is the chief medical officer of the Centers for
Medicare and Medicaid Services.

You can find links to Robin Fields' article investigating the quality of care
at dialysis centers and the cost of treatment on our website, freshair.npr.org.

Coming up, David Bianculli reviews last night's premiere of Conan O'Brien's new
show on TBS.

This is FRESH AIR.

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Conan's Back: Is His Third Show The Charm?

TERRY GROSS, host:

Conan O'Brien got his first TV talk show when he succeeded David Letterman as
host of NBC's "Late Night" in 1993. More than a decade later, Conan got his
second TV talk show when he succeeded Jay Leno as host of NBC's "Tonight Show."
That job lasted less than a year before Conan walked away and Leno was
reinstated. Last night, Conan O'Brien returned to TV as the host of "Conan,"
his new talk show series on the basic cable network TBS.

Our TV critic David Bianculli has this review.

(Soundbite of TBS, "Conan")

(Soundbite of applause)

Mr. CONAN O'BRIEN (Host, "Conan"): Thank you and welcome to my second annual
first show. That's...

(Soundbite of laughter)

DAVID BIANCULLI: They say you never get a second chance to make a good first
impression - but if you're a TV talk-show host, that rule doesn't hold. Every
time you launch a new show, you get more attention and more reviews - and
usually more viewers - than at almost any other time. But after that opening
night, as viewers decide what's changed and what hasn't and what's appealing
and what isn't, things start to level off quickly.

The first time Conan hosted a talk show, virtually no one knew who he was. So
he was building his comic identity from scratch, and without much support from
NBC. The second time, when he inherited "The Tonight Show," ratings for the
first few nights were very solid - but then the more conservative viewing
audience decided Conan was an acquired taste they were in no hurry to acquire.
Conan tried to book and alter the show to appeal to the mainstream, but didn't
succeed - and, once again, didn't get much support from NBC.

But now he's on basic cable, where things are just a little looser, and where
Conan O'Brien can play to his audience, doing what he wants to do. That's the
theory. But in practice, in Monday's opening show, there seemed to be more
constraints and stiffness, not less.

This was Conan's third chance to make a good first impression, and I'm sorry to
say, this time he fell flat. As flat as the interview segments, which were
painful to watch.

The celebrity guests for opening night of "Conan" were Seth Rogen - seemingly a
solid-gold booking for Conan's college-age stoner fans - and Lea Michele, the
"Glee" star who has similarly strong appeal for a younger audience. And the
musical guest was Jack White, who played an old rockabilly tune with Conan and
the show's Basic Cable Band.

The music was fine and energetic and fun. The conversations were not.

Both guests were guided, rather awkwardly, through their prepared stories. Seth
Rogen talked about proposing to his girlfriend and joked about the ease of
getting a prescription for medical marijuana in California; Lea Michele talked
about no one being aware of her singing talent until she tried out for her
first Broadway audition - a story that lost its punch when she explained that,
at the time, she was eight years old. Conan also asked about her recent sexy
photos in GQ magazine, but that was only to set up a bit where a high school
picture of himself was inserted into that photograph.

But hey, at least it was a visual. Otherwise, the guests arrived empty-handed.
Rogen was promoting his next movie, "The Green Lantern," but didn't have a clip
because the movie is still two months away. And Lea Michele didn't show a clip
from tonight's installment of "Glee" because - well, I don't know why.

What I do know is that the parts worth watching, much less remembering from the
first installment of "Conan," were few. The opening filmed piece which traced
his move from NBC to TBS was okay, but not the caliber you'd expect from a
piece they had months to prepare. I still remember how Conan opened his version
of "The Tonight Show" running across the country because he'd forgotten to move
from New York to L.A.

I liked Conan's musical and vocal duet with Jack White on Eddie Cochran's
"Twenty Flight Rock," and I liked portions of Conan's monologue, where, on
occasion, he delivered the sort of warped perspective that I've come to expect.

(Soundbite of TBS, "Conan")

(Soundbite of laughter)

Mr. O'BRIEN: The worst thing is this though, I put myself and my staff through
this crazy huge ordeal, all because I refused to go on at midnight, okay?

(Soundbite of laughter)

Mr. O'BRIEN: And so, I work, you know, and then I get this job at 11, it's
supposed to be a big deal, then yesterday, daylight savings time ended.

(Soundbite of laughter)

Mr. O'BRIEN: Right now it's basically midnight.

(Soundbite of laughter) (Soundbite of applause)

Mr. O'BRIEN: What the hell was that all about?

(Soundbite of cheering) (Soundbite of applause)

Mr. O'BRIEN: I'm an idiot.

BIANCULLI: But the rest?

Andy Richter, returning as sidekick, added better conversational ad-libs than
Conan did, but their exchanges often seem to exclude, rather than embrace, the
audience. And all that fuss last night about the background set, with its
three-dimensional moving moon? That reminded me of opening night on Chevy
Chase's talk show on Fox, where he made a big deal of having a real tropical
fish tank behind him, with real tropical fish.

It quickly became obvious, on that show, that the fish were the only thing
worth watching. If the scenery on "Conan" is more fun than the guests - and on
opening night, it was - something is starting out very, very wrong.

GROSS: David Bianculli is founder and editor of TVWorthWatching.com and teaches
TV and film history at Rowan University in New Jersey.

(Soundbite of TBS, "Conan")

Mr. O'BRIEN: It's a thrill to have this gentleman on our first show. Please
welcome our good friend Mr. Jack White.

(Soundbite of cheering) (Soundbite of applause)

(Soundbite of song, "Twenty Flight Rock")

Mr. JACK WHITE (Guitarist, band member, The White Stripes): (Singing) Well...

Mr. O'BRIEN: (Singing) I said, well...

Mr. WHITE: (Singing) Well, I've got the girl with a record machine. When it
comes to rocking she's the queen. We love to dance on a Saturday night. All
alone, I can hold her tight. But she lives in a 20th floor up town. The
elevator is broken down.

Mr. O'BRIEN AND Mr. WHITE: So I walked one, two flight, three flight, four...

GROSS: You can download a Podcast of our show on our website, freshair.npr.org.

I'm Terry Gross.

(Soundbite of song, "Twenty Flight Rock")

Mr. WHITE: (Singing) This went on for a couple of days. But I couldn't stay
away.
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Transcripts are created on a rush deadline, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of Fresh Air interviews and reviews are the audio recordings of each segment.