A Moiliili dialysis clinic held its grand opening ceremony Tuesday after sitting virtually unused for three years, the victim of a slow state inspection process.

The U.S. Renal Care Beretania Dialysis Clinic needed an initial inspection in order to admit patients insured by Medicare or Medicaid, two government-run programs. About 85 percent of Hawaii patients rely on those programs, so state inspectors must confirm the facility meets federal standards before operators can be reimbursed.

The 17-chair center could only serve a couple of patients with commercial, or private, insurance while it was stalled in the state’s lagging certification and inspection process.

A 24-chair Mililani clinic run by Liberty Dialysis faced a similar predicament, but has also recently begun admitting Medicare and Medicaid patients.

An employee photographs U.S. Renal Care’s latest facility at 1908 S. Beretania St. Courtney Teague/Civil Beat

Another 13 clinics are up for recertification this year, but the state has identified a contractor to help with recertification inspections while new employees await the specialized training necessary to survey a dialysis clinic.

At the Beretania clinic Tuesday, company employees and executives celebrated with balloons, shoyu chicken, and a chocolate cake framed by an orange frosting lei which read, “Congratulations USRC Beretania.”

Patients had been on the clinic’s waiting list for more than a year. Prospective patients would routinely stop by the clinic and ask whether it was ready to open, said Sunny Ku, an administrator at the Beretania clinic.

“Finally I can pick up the phone and call them and transfer (them) to our clinic,” he said. “You can hear they’re really happy on the other end.”

‘A Life-Changing Event’

The Beretania clinic currently has about 20 patients but can take up to 100.

Most patients live nearby and some are even within walking distance, Ku said. Some faced an hourlong commute to their previous clinic.

The short commute is important for patients because it can take six to 24 hours for a patient to recover from dialysis, said Pliny Arenas, who oversees U.S. Renal Care operations in Hawaii.

For Arenas, the turning point with the state came after Rep. John Mizuno, chair of the House Health and Human Services Committee, held a January meeting to discuss the backlog of dialysis center inspections.

The Beretania clinic has 17 chairs, including one in a private room. Courtney Teague/Civil Beat

“That gives the assurance that we can confidently provide more services to the (end stage kidney disease) population in the state of Hawaii,” Arenas said.

Arenas confirmed U.S. Renal Care is looking to open another five clinics in high-need areas, but declined to elaborate on plans.

Mizuno announced at the January meeting that he would introduce legislation in an effort to provide the health department with additional positions and funding to inspect dialysis centers. The U.S. government covers 80 percent of the cost because state inspectors perform work on behalf of the feds.

House Bill 1895 hasn’t been signed by Gov. David Ige yet, but didn’t make the short list of bills that he intends to veto.

While Arenas is pleased with the progress that’s been made, he’s  worried that history will repeat itself if the bill’s promises fall through. Another 130,000 Hawaii patients have chronic kidney disease and will eventually need dialysis.

When much-needed dialysis clinics can’t open, patients are forced to take inconvenient treatment slots. It hurts clinic business operations too, he said.

“Dialysis is a life-changing event,” Arenas said. “When someone tells you that you will be on dialysis, you will be at the clinic three times a week” or dialyzing at home even more often.

New Priorities

The federal Centers for Medicare and Medicaid Services contracts with state inspectors to verify facilities meet their standards.

Part of the reason the Moiliili and Mililani dialysis centers weren’t able to gain certification for years is because the feds set priorities for state inspectors.

Dialysis centers have historically been lower priority, but that changed recently when the U.S. Centers for Medicare and Medicaid Services made inspection of new dialysis centers a top priority.

Fresenius Kidney Care dialyzer, this cartridge filters contaminants from the blood like an actual 'kidney'. This dialyzer is atttached to the Hemo Dialysis Machines and the patient sits for four hours during dialysis.
Rose Bombards, clinical manager of a Liberty Dialysis center in Salt Lake, shows off a cartridge that filters blood and acts as an artificial kidney. Cory Lum/Civil Beat

This prompted the state Department of Health to send its surveyors, or inspectors, to visit the new dialysis centers and postpone other inspections, according to department spokeswoman Janice Okubo.

The Beretania clinic was inspected in February and the Mililani clinic was inspected in March, Keith Ridley, head of the Office of Health Care Assurance, said in an email.

No new dialysis centers are waiting for inspections.

Five of the health department’s 12 inspectors are trained to conduct dialysis center inspections, Ridley wrote. Newer inspectors must complete basic training before they can learn to inspect dialysis centers.

Thirteen dialysis centers are up for a recertification inspection this year, five of which are past due but continue to operate.

Those 13 facilities will be surveyed by a contractor who is expected to begin Aug. 1, Ridley said.

High Demand, High Prices

Dialysis centers are in high demand here for several reasons.

Asian, Pacific Islander and Native Hawaiian populations are particularly susceptible to kidney disease. One in seven Hawaii residents, or 168,000 people, suffer from chronic kidney disease. Nationally the average is one in nine.

Dialysis is needed when patients develop end-stage kidney failure.


Treatment is pricey. An average patient could pay about $4,500 per week.

That’s why the vast majority of Hawaii patients rely on Medicare or Medicaid — often in addition to the insurance they obtain through work — and why it’s so important that new dialysis centers receive timely inspections and certification. The state’s largest insurer, Hawaii Medical Service Association, also requires patients visit federally certified centers.

When facilities sit unopened, it can have a major impact on patients and the health care system overall.

Many patients find out they need dialysis during a trip to the hospital. Patients can’t leave between treatments because high discharge rates can jeopardize a hospital’s federal funding.

Some wait at the hospital for weeks until a treatment slot opens up, taking up bed space for others who may need it.

Patients who do receive outpatient treatment may face long commute times because no treatment slots are available near their homes. Others have to drive themselves because they can’t take public transportation or catch a ride with family.

Some health care professionals say Hawaii has an unusually high proportion of patients who receive outpatient treatments, as opposed to receiving treatment at home. It’s unclear why.

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