Emergent Dialysis - PD

I’m a safety net nephrologist, retired from battling for ~ 50 years for Medicare4All, who works in a “safety net clinic”, part-time. We see undocumented, uninsured patients helping them transition from excellent primary care to ESRD. There is a governmental push to contain costs with one of the solutions being home dialysis, and a patient has been cleared by a non-profit dialysis clinic chain as a candidate for peritoneal dialysis, which he prefers over home hemodialysis. Though he has an option to obtain full scope Medicaid (MediCal, in California), he must qualify: 1) financially, 2) inform immigration that he is in the USA, and keep them informed, 3) know that he is subject to “Public Charge” rules should he apply for legal residency and eventual citizenship. This is called PRUCOL (Permanent Residency Under Cover of the Law). We have few takers! After legal advice, most choose not to have full scope insurance, so they enter ESRD via the ER, ICU, Acute HD via CVC, obtaining full scope MediCal, and can then start PD. Insane! But, until the country comes to its senses, it is what it is. Then, I, a paleolithic nephrologist, heard about emergent PD, and watched a great video with a fabulous Canadian surgeon on this website. He’s in Canada, and I’m in San Rafael, CA. Now, can you help me find a few great articles, or do it yourself instructions for the well meaning surgeons, general or vascular, that have little to no experience in putting in catheters that will be used immediately for dialysis, thereby qualifying the patient for full scope MediCal and the non-profit dialysis clinic for reimbursement for supplies and training? Your advice and experience would be most helpful.

Dr. Agar is from Australia so he doesn’t have to deal with our immigration issues in the U.S. I reached out to a friend and fellow nephrology social worker (NSW) in southern CA and shared your question with him. Here’s what he wrote to respond to your question.

PRUCOL applications are usually taken at face value by Medi-Cal (the Dept of Public Social Services or DPSS). Although at one point we NSWs were told by attorney and Medi-Cal expert Toni Vargas of Neighborhood Legal Services / Health Consumer Center (who is a regular presenter at our local Council of Nephrology Social Workers chapter semi-annual meetings) that some cross-checking / verification had begun between government agencies, most Medi-Cal eligibility workers see a PRUCOL application and automatically change the beneficiary’s type of coverage from emergency Medi-Cal to regular full-scope Medi-Cal. This allows the beneficiary to qualify for a kidney transplant evaluation and to have his/her case assigned to a county Medi-Cal health plan in order to qualify for vascular surgery and transportation benefits – none of which are provided under emergency Medi-Cal. Never in my 21 years as an NSW have I had any patient be confronted by or have trouble with any government immigration agency as a result of self-reporting their presence under PRUCOL. And that is because Medi-Cal usually does not share that information; the eligibility worker sees the form, makes the change to regular full-scope, and files the paperwork away with all other documentation. Reporting a PRUCOL applicant to INS or whoever is very rare. I explain this to any potential candidate and, unlike the MD, the vast majority choose to apply. More recently, all beneficiaries’ cases change and within at the most 3 months; unlike before when it was more of a hit-and-miss when some beneficiaries never got changed over, some did but then it reverted back to emergency status, some did but many months after the application, etc. Now it is much more known about and accepted. California is a very, very liberal state and there is a generally large push to get persons into government programs such as Medi-Cal, Covered California (ACA), Cal Fresh (food stamps), school meal programs, Calif First Five, etc, especially immigrants. There are billboards and TV commercials advertising these programs and encouraging those experiencing poverty to sign up, including immigrants.

Usually the PRUCOL application is done fraudulently by the immigrant patients as they declare themselves on the form an already PRUCOL immigrant (under the miscellaneous category) which is not true. But, as mentioned, Medi-Cal takes the declaration at face value and usually does not verify any of the information given. And the form is extremely simple to complete. Toni has suggested that all NSWs DO NOT assist patients with the form as they are technically committing a crime in doing so; instead, she recommends that NSWs provide education and steer the patients to the form, and send them to DPSS. Here in Los Angeles, Harbor-UCLA (an LA County medical center) will actually help our patients that we send them with emergency Medi-Cal to fill out the forms and be converted to regular Medi-Cal so that they will qualify for transplant evaluation.

As a SW supervisor of many pre-licensed MSWs, I, too, recommend that they take a hands off approach to PRUCOL applications and follow Toni’s advice. I don’t want them to place their licenses / careers in any kind of risk. I myself, however, actually help my patients fill out the form and submit it. I am nearing the end of my career and feel that I can afford the risk of losing my license although I think that that would certainly be a longshot. I do it because it is a win-win-win all the way around – getting a transplant (and receiving other benefits) improves the QOL and longevity of all patients; and because they are “healthier” because of it, the state saves money on hospitalizations and other results of poor performance measures and on paying forever dialysis instead of cheaper-in-the-long-run kidney transplant.

In terms of public charge, the Medi-Cal program no longer requires payback to the state once a beneficiary and spouse expire; and I am not aware of any consequence on immigration path (legal or otherwise) by participating in our state’s Medicaid program.

I have had at least one PD patient who had emergency Medi-Cal and was on PD, so I take it that Medi-Cal-only patients (emergency or full-scope) qualify for PD. However, I have never had a patient on emergency Medi-Cal initiate RRT as a PD pt, so I’m not sure how someone would go about that. The vast majority of patients crash into dialysis so they get a vascular cath and start HD; however, like everyone else, they can be evaluated right away for home modalities, have a PD cath placed instead of a fistula, and proceed to transition to PD when indicated by the interdisciplinary team.

My input is based on my experience only, and in Southern Calif. Perhaps there is a different system in Northern Calif. I also suggest that you contact others in No Calif, such as Anne Pugh (APugh@hsag.com) or Riquelen Ngumezi (RNgumezi@hsag.com) at ESRD Network 17 who both have extensive experience in dialysis clinics up there before transitioning to their Network positions; as well as Toni Vargas. Her contact info is:
Toni Marie Vargas
Neighborhood Legal Services
13327 Van Nuys Blvd
Pacoima, CA 91331-3006
Los Angeles County
Phone: (818) 834-7558
Fax: (818) 834-7552
Email: tvargas@nlsla.org

Thank you, Beth. The information that you wrote is extremely useful, and I want to thank you for the exceptional attention to the plight that I described. Even when a problem can not be completely resolved, the support and concern of fellow workers and the insights received, fully re-enforce the intentions and mission of this community. Your response is a tribute to your commitment and for me, a source of great pride, that the community exemplifies why so many are drawn to the field of healthcare. Thank you, and I shall use the information to inform those I work with to be sure that the patient has everything he needs to make the best choice for his situation.