If you live in Southwest or Southside Virginia, you have a higher chance of suffering from kidney disease than others in the state.
The Virginia Department of Health says that the highest rates of diabetes — which is often connected with kidney disease — are in the Southwest Virginia Health Region that includes everything west of Danville and south of Alleghany County. In that part of the state, 15.7% of adults 18 and older have been diagnosed with diabetes, a rate more than twice that in Northern Virginia.
The single highest diabetes rate in the state, according to County Health Rankings, is in Danville, where 15% of adults 20 and older have been diagnosed with the disease. (Note the age difference between these two measures.)
The state does not make available locality-by-locality data on chronic kidney disease, but if we look just at Medicare beneficiaries 65 and older, the highest rates of CKD in the state tend to be primarily in Southwest and Southside, according to the Centers for Disease Control:
Dickenson County 33.80%
Prince Edward County 33.33%
Shenandoah County 31.71%
Pulaski County 31.67%
Martinsville 31.46%
Craig County 31.43%
Buena Vista 31.15%
Caroline County 30.77%
Greensville County 30.00%
Frederick County 29.94%
If you live in Southwest and Southside, and have kidneys, functioning or otherwise, there’s a slow-moving bureaucratic contest taking place in Richmond that potentially affects you.
The outline goes like this: Carilion Clinic in Roanoke wants to open a kidney transplant center. The University of Virginia Health System in Charlottesville opposes this, and a staff analysis by the Virginia Department of Health last year likewise took a dim view of Carilion’s proposal and recommended it be denied. On Tuesday, there’s a hearing in Richmond that will review Carilion’s response to that staff recommendation.
I approach this topic gingerly because Carilion is one of our donors and, while donors have no say in news decisions (see our policy), I don’t want to give the appearance that we’re championing a donor’s cause. On the other hand, our raison d’être is to champion Southwest and Southside, so I’d be remiss if I didn’t take a look at the issues involved here.
1. The policy issue here is state regulation of health care.
Virginia is one of 39 states with a “Certificate of Public Need” law. That means a hospital can’t just start a new program because it wants to; the state has to find that there’s “public need” for the service. The rationale is to avoid costly arms races between rival hospitals that drive up costs for patients; the other point of view is that these requirements don’t achieve their stated goal and constitute interference in the marketplace. The health care news site Health Care Dive reported just last week that some states are rolling back such laws “in the face of growing demand for healthcare and mounting evidence that they might not lower spending.” We will not resolve that question today. However, it’s the existence of Virginia’s Certificate of Public Need requirement that gives the state the final say in whether there’s a kidney transplant program in Roanoke.
2. The dispute is over whether competition in Roanoke will weaken the University of Virginia transplant program in Charlottesville.
The University of Virginia believes a kidney transplant program at Carilion “portends significant risk” to its program in Charlottesville, on the grounds that “Carilion’s program would rely on diverting patients from UVA.” That, UVa says, “will threaten quality staffing, UVA’s training missions and research initiatives, and the viability of many of the transplant-adjacent services that UVA provides, many of them specifically focused” on Southwest and western Southside. For instance, UVa operates kidney-related clinics in Lynchburg, Martinsville and Roanoke, with a clinic in Marion in the planning stages. Yes, there’s money involved. UVa says, “The diversion of patients also seems poised to focus on better-insured patients, at risk to the financial sustainability of UVA’s services.”
In response, Carilion says a program in Roanoke wouldn’t hurt UVa’s finances.
Some numbers: In fiscal year 2022, UVa performed 147 kidney transplants. Of those, 58 came from the health region from Danville to the west. However, Carilion says only 34 of those came from its service territory. Carilion says it’s likely that some of those patients would have chosen to go to UVa even if Carilion were an option. However, even if all of those 34 did pick Carilion, “UVA will still maintain substantial kidney transplant volumes of well over 100 cases per year.”
How much would losing 34 transplants a year to Roanoke endanger UVa’s program? That’s part of what state regulators will ultimately decide.
3. State regulators are forbidden from considering what might be key facts.
UVa says that Carilion’s program would be small and that “smaller programs can correlate with worse outcomes because — as UVA again suspects would be the case with Carilion — smaller programs simply cannot sustain the range and redundancy of complex clinical support services required by transplant patients.” I’m in no position to adjudicate that, but I can point out a curious rule: When evaluating Certificate of Public Need requests, state regulators aren’t allowed to consider out-of-state programs. There may be good reasons for that — presumably, the theory is that Virginia should take care of its own — but it also means that regulators can’t judge the Carilion program in the light of transplant programs in North Carolina and Tennessee.
The odds seem good that some Virginia patients in Southwest and Southside wind up going to the hospitals at the University of Tennessee, Wake Forest University and Duke University for kidney transplants. That means the potential Carilion market is probably bigger than just the 34 Carilion-area patients who went to UVa. I attempted to get figures from those three programs on how many Virginia transplant patients they deal with, but none would provide them. If regulators are concerned that Carilion’s program would be too small, it might be because they’re not allowed to look at all the information.
4. This is partly a dispute over a map.
The rule is that transplant patients shouldn’t have to travel more than two hours to get to a transplant center. Roanoke, depending on how fast you drive and what the traffic on Interstate 81 is like, is within two hours of Charlottesville. This is the map that matters. The part of Virginia in yellow is within two hours of existing kidney transplant centers. If Carilion had a kidney transplant center in Roanoke, then the part in blue would be covered. The remaining parts of Southwest Virginia that aren’t colored in would still be outside a two-hour drive from Roanoke.
Part of what’s in dispute is whether that blue zone has enough people for the state to worry about. The Department of Health staff report dresses that up in different language, but that’s what it comes down to. How many people are we talking about? Carilion says there are 878,757 people in Virginia who are more than two hours from an existing kidney transplant program in Virginia — because, as state rules require, it’s not taking into account out-of-state programs. UVa says there are only 7,864 people in Southwest and western Southside who are more than two hours away from a kidney transplant program, be it in-state or out-of-state (although Carilion points out that regulators aren’t supposed to consider those out-of-state programs).
How many people are in that blue zone? My rough math counts 510,520.
The key question for state regulators is how they feel about those 510,520 or so people: Is it worth decreasing UVa’s kidney transplant revenue to bring those people within two hours of a kidney transplant center? I suspect people who live there might feel differently than the state health department staff on that question.
Of note: That blue zone, which covers all or parts of 19 localities, includes a) Danville, which has the state’s highest diabetes rates and b) three localities (Pulaski County, Martinsville, Craig County) where more than 30% of the Medicare beneficiaries over 65 have chronic kidney disease.
5. How much competition is too much?
UVa says that competition from Carilion, two hours away in Roanoke, would pose a “significant risk.” Carilion, in its response, points out that UVa already has competition that’s closer — the Henrico Doctors Hospital and Virginia Commonwealth University Medical Center are both an hour away from Charlottesville. The implication: UVa is picking on a smaller competitor in a smaller part of the state. On the other hand, most of those other programs are long-established. VCU started performing kidney transplants in 1957; UVa in 1967. Henrico Doctors Hospital started in 1990.
For what it’s worth, VCU doesn’t regard the Carilion program as competition. Two top executives of the VCU health system have written letters of support on Carilion’s behalf and offer certain services.
Now, here’s where things really get interesting.
6. Carilion had a kidney transplant program in the 1990s.
If Carilion gets approval for a kidney transplant program, it won’t be the first one. From 1993 to 1997, Carilion performed 76 kidney transplants, an average of about 15 per year. The program was discontinued after the lone transplant surgeon left. Interestingly, no other hospital objected to Carilion’s application for a Certificate of Public Need in 1993. When the program shut down, The Roanoke Times reported in 1997 that the University of Virginia had performed 70 transplants the year before. In 2022, it performed 181 (the smaller figure cited earlier is for a fiscal year, not a calendar year). Carilion’s kidney transplant program didn’t pose an economic threat to UVa when the Charlottesville facility was performing 70 transplants a year; why does it do so now when it’s performing 181?
Once Carilion ended its program in 1997, the original Certificate of Public Need expired. We can only speculate where that program would be today if it had continued. Finally, let’s do so.
7. Since the 1990s, Roanoke has developed a health care economy.
When Carilion announced in 1991 that it was going to pursue a kidney transplant program, the Roanoke Valley was in a very different place, economically and psychologically. The Roanoke Valley then was still in the mourning period after losing the Norfolk and Western Railway headquarters in 1982 (upon the merger to become Norfolk Southern) and grappling with what sort of community it wanted to be. More to the point, it was not clear in the early ’90s that the Roanoke Valley would evolve from an industrial city into one where health care dominated.
In 1991, the Roanoke metro had more manufacturing jobs than health care jobs. Now that’s reversed, as the number of manufacturing jobs has declined by 28% and the number of education and health care jobs has risen by 55%, according to the Federal Reserve. (I wish the federal government separated those two into separate categories, but they don’t, and we have to work with what we have.)
The Bureau of Labor Statistics says that education and health is now the second-biggest employment sector in the Roanoke Valley, behind only trade, transportation and utilities. Almost one of every five workers in the Roanoke Valley is now connected to health care. Some of that is due to national changes — an aging population requires more health care. Some of it is due to more local ones — in the early 1990s, Roanoke didn’t have a medical school or a biomedical research institute. Now it does, and together they are seen as a key driver of the local economy. Had that 1990s kidney transplant program continued, it’s possible, even likely, that the Roanoke Valley might have become an even bigger health care capital than it already is. At the time, Carilion leaders talked about expanding the transplant program to other organs, even heart transplants, once it had become established. That never happened. None of that will, or should, matter to state regulators, but it helps us put this latest request in a historical context.
In the meantime, take care of your kidneys — drink plenty of water, eat a healthy diet — because you’d like to avoid having to get a kidney transplant, no matter where you might have to go for it.
See also two previous opinion pieces, one from Carilion and one from the University of Virginia.
Ranked choice voting, special elections, plus elephants and venison, too.
Those are some of the issues we deal with this week in West of the Capital, our weekly political newsletter that goes out on Friday afternoons. You can sign up for that or any of our other newsletters here:
