Kidney doctor's shooting comes as questions emerge about dialysis centers
Dr. Andre Obua drove 18 hours from Miami to Terre Haute, Indiana. He pulled up to the home of a local kidney specialist and allegedly opened fire, striking the kidney doctor in the hand before being wrestled to the ground.
The only thing more unexpected than the act of violence was the apparent motive.
Accused in the shooting, which occurred one month after the brazen murder of the UnitedHealthcare CEO in New York City, was Obua, a highly educated medical resident with a promising career. But Obua had become fixated on one of the least-understood corners in the big business of medicine — kidney dialysis.
In letters penned from prison, in phone interviews and on a website he created, Obua shared with CBS News his grievances, discussed the Luigi Mangione case in New York, and offered hints to the underpinnings of an alleged act that landed him in jail, where he is awaiting trial on attempted murder charges. He would not directly discuss the shooting and has pleaded not guilty.
Prosecutors in Vigo County, Indiana, said they consider the crime abhorrent — and a source of continued pain for the physician who was shot. CBS News is not naming the victim at the request of prosecutors. Prosecutor Terry R. Modesitt said his office determined the victim "had never done anything to justify having violence brought against him." Modesitt voiced a broader concern about what he said he fears is a growing wave of disturbing vigilante violence that has no place in a civilized society.
"These cases that we read about in the news or watch on TV about the news — there's no excuse for this," Modesitt said. "Go out and protest. Write your congressman… file a complaint with the attorney general's office in your state, things like that. But no, there's never any justification to go try to murder someone."
Tom Mueller, the author of "How to Make a Killing: Blood, Death and Dollars in American Medicine," spent more than five years studying the dialysis industry. He says the incident conjures many of the same complex swirl of emotions that Americans expressed after the UnitedHealthcare shooting. There is a visceral disgust for violence used to make a statement, he said. And there is long-running dismay about the shortcomings of America's health care system, which may be costing lives. That includes, he said, a rise of for-profit dialysis clinics and their impact on quality of care for those confronting end-stage kidney disease.
"Unless we can talk about systemic harm done by the medical profession, the insurance profession, against patients … we're not gonna get anywhere," Mueller said.
Mueller may be uniquely positioned to weigh in on both the crime and the issue that may have been underlying it. For months before the shooting, he told CBS News that he and Obua had been corresponding by email about his book. In those emails, which he described to CBS News, he says Obua never gave any indication he was spiraling towards violence. Mueller only learned of the shooting later, during an interview with CBS News.
"I nearly fell off my chair when I heard," Mueller said. "My sense is that [his] level of desperation just must have found an outlet in a violent act."
Dialysis under scrutiny
LaQuayia "LQ" Goldring, 28, has been a dialysis patient for the past ten years. Goldring lives near Louisville, Kentucky, where she spends up to four and a half hours a day hooked up to a home dialysis machine. It acts as her kidneys, taking the blood from her body, removing the waste, then cycling it back in.
"Every day I wake up, I'm thanking God that my feet even hit the ground and that my eyes open and I can still breathe on my own," she said.
Goldring is one of roughly 500,000 Americans dependent on dialysis to stay alive as they wait and hope for a kidney transplant, the only available remedy for those suffering from end-stage kidney disease. She receives the treatment at home, and says dialysis clinics left her with no control over her care, treating her like a "check." She, like Mueller, believes the industry has become too focused on profits.
"This is emergency room care done in the mall," Mueller said. "People are not given the tailored treatment that they need."
A review of federal data by CBS News found one-third of dialysis clinics failed to meet federal standards this year — nearly 2,500 of the roughly 7,600 clinics nationwide. The average score was 60 out of 100 possible points.
Criticism of the industry has been disputed by the two largest for-profit companies in the dialysis industry, Fresenius and DaVita.
Fresenius told CBS News in a statement that the company maintains an "unwavering focus on improving quality of life, strengthening clinical outcomes, and extending the lifespan of those we have the privilege to serve." DaVita said in a statement that its "dedicated clinicians consistently deliver high-quality, individualized care in a complex clinical and regulatory environment."
A health care "duopoly"
The two companies dominate the national landscape of clinics where kidney patients come to receive regular dialysis treatments — crucial to keeping them alive. Roughly 90% of patients get their treatment in the outpatient clinics. And together, the two for-profit companies own nearly 75% of all U.S. clinics — nearly 5,600 in total.
The companies have become what Mueller calls "a duopoly" as the industry has consolidated over the past three decades. The share of independently owned dialysis facilities fell from 86% to 21% during that period. In over 2,500 cities around the U.S., a single company owns every clinic.
That industry dominance has a cost, according to Ryan McDevitt, a Duke University economist who co-authored a study released this month looking at the toll of the scarce competition.
"This is the most concentrated health care sector across the entire U.S.," McDevitt said.
McDevitt argues that Medicare's limits on how much it reimburses clinics per patient have incentivized DaVita and Fresenius to focus on filling chairs to increase their profit margins. Both companies reject that characterization.
Last year alone, DaVita delivered more than 29 million dialysis treatments, earning $391 in revenue per session. That includes providing home dialysis treatments, like Goldring receives through Fresenius. Together, Davita and Fresenius reported a total of $33.7 billion in revenue from all of their businesses.
McDevitt said his research found that when independent clinics are acquired by DaVita or Fresenius, their transplant referrals drop by about 10%, their patient survival rates fall by 2%, hospitalizations increase by 5%, and infection rates go up by about 12%.
While kidney specialists typically dictate the type of care they want for their patients, some doctors told CBS News they felt pressure from the companies running the dialysis clinics to move patients through faster. Dr. Leonard Stern, a nephrologist now at Columbia University, said even if he believed a patient needed five hours of dialysis treatment, there were times that DaVita would refuse.
"We have a corporate model that provides the least amount of care for the most amount of profit for shareholders," Stern said.
Stern served as medical director of an independent for-profit dialysis center until 2005, when it was sold to DaVita. After the acquisition, he said there were times the company instructed him to make more room for new patients. He said that sometimes meant more billing for DaVita, even if it resulted in unnecessary complications and return visits for his patients.
Stern left the clinic in 2013.
Dr. Jeffrey Gold, a kidney specialist in Royal Oak, Michigan, said the doctors feel pressure to "get the next patient in — and make sure everybody has a spot to dialyze."
McDevitt described the one-size-fits-all approach as inconsistent with patient needs.
"They call it bazooka dialysis, where they pump you through the station as quickly as possible," McDevitt said, comparing the turnover model to any other volume business. "They need to turn over stations multiple times a day to hit those profit numbers, to keep shareholders happy."
Reports of deficiencies
Most dialysis patients rely on the federal government to pay for the treatment. The costs add up to about $40 billion a year, according to the American Association of Kidney Patients.
"It's actually one percent of the entire federal budget, which is a staggering statistic," McDevitt said.
Despite the expenditures — about $100,000 per patient, according to McDevitt — the U.S. has among the highest death rates for patients on dialysis among developed nations.
For years, health surveyors from the Center for Medicare and Medicaid Services (CMS) have conducted routine monitoring of dialysis clinics to assess their performance.
Since 2013, those officials have cited U.S. dialysis centers for more than 115,000 deficiencies, including poor hand hygiene, unsanitary conditions while handling IV medications, and inadequate training.
CMS assigns every facility a "Total Performance Score," evaluating them annually on measures like patient safety, infection control and hospitalization rates. If the score is below CMS standards, the clinic is hit with a financial penalty.
A CBS News review of federal data found more than 40% of the clinics run by the nation's two largest dialysis providers — DaVita and Fresenius — failed to meet those same standards this year. That's nearly 1,600 clinics.
In separate statements to CBS News, both companies highlighted their performance, saying the data reflects a track record of "exemplary care."
Fresenius noted that more than 65% of its dialysis centers received three stars or higher on Medicare's five-star scale — a rate the company said is higher than the national average of all U.S. dialysis providers. The company also said its employees "take immense pride in providing best-in-class, high-quality care to our patients."
DaVita said in a statement to CBS News that problems in clinics were "rare and isolated" and represent "exceptions and do not reflect the exemplary care we consistently provide."
"We take every concern seriously, and if we make an error, we work immediately to resolve it," DaVita said in its statement. "To mischaracterize such anomalies as systemic care failures is reckless, fear-mongering, and puts patient well-being at risk."
Legal settlements top $1 billion
The dialysis industry has faced legal scrutiny over the past decade from patients, their surviving relatives, and from state and federal agencies.
One ongoing federal case against Fresenius accuses the firm of trying to fraudulently obtain hundreds of millions of dollars of federal funds by performing unnecessary procedures — an allegation the company denies. The two companies have settled at least 25 lawsuits. And CBS News has found that since 2015, Fresenius and DaVita paid out at least $1.13 billion in legal settlements.
"I have not seen any improvement in care following these settlements," McDevitt said.
A spiral towards violence
Frustration over the lack of reform in the industry has been simmering for years, Mueller told CBS News. Which is why Mueller said he was not unnerved as he exchanged emails with a Miami-based medical resident who had taken an interest in dialysis — and specifically, the use of a specific medication he thought could be harming patients.
"The kinds of emails he sent were totally rational, very thoughtful, extremely data-driven," Mueller said, calling Andre Obua "the last person in the world I would think to commit a violent act."
Over dozens of pages, the letters Obua sent to CBS News from jail describe how he grew up in a low-income household in Ann Arbor, Michigan — a background that "shaped my world views and motivates me to advocate for the less fortunate," he wrote.
He says he first heard during an internal medical rotation about the use of a medication being prescribed to kidney patients to speed up the dialysis process, which he speculated could be endangering their health. It appears from his writing that this concern went from being an interest to being an obsession.
At one point, he described seeking out a lawyer to file a whistleblower lawsuit, but was ultimately persuaded he could not succeed in court.
CBS News sought to verify his claims, but no kidney expert interviewed believed that the medication in question harmed patients. Nevertheless, Obua unspooled mountains of his research, theories and accusations on a public website.
A source familiar with the case told CBS News Obua had drawn up a list of kidney doctors to target. Near the top was the victim of his attack in Indiana.
In January, for reasons Obua would not directly address in his letters and conversations with CBS News, the 29-year-old said he loaded his car with firearms and a bag of Monopoly money — which he noted was similar to the one left behind by alleged UnitedHealthcare shooter Luigi Mangione — and headed north towards Indiana.
Police reports say Obua fired at a Terre Haute kidney specialist without warning, striking the doctor in the hand. The two wrestled in the tranquil suburban driveway until police arrived and placed Obua under arrest.
Mueller shakes his head when thinking about the bright future Obua seemingly abandoned that winter evening.
"It says we're living in extreme times," he said. "And it's a tragic, tragic event."
Modesitt, the prosecutor, said he has no sympathy for the young medical resident who's now facing attempted murder charges.
"If you've got a problem in any way with the system or anything else, we have attorney generals, we have secretary of states, different entities that you can file a complaint with," Modesitt said. "But it's never justified to take the law in your own hands."
Obua is scheduled to go on trial in August.
Full statement of DaVita:
Our dedicated clinicians consistently deliver high-quality, individualized care in a complex clinical and regulatory environment. We understand that in any healthcare setting, rare and isolated incidents may occur. However, these are diligently addressed as exceptions and do not reflect the exemplary care we consistently provide. We take every concern seriously, and if we make an error, we work immediately to resolve it. To mischaracterize such anomalies as systemic care failures is reckless, fear-mongering, and puts patient well-being at risk.
Full statement of Fresenius Medical Care:
Providing high-quality care is our standard, and nothing gets in the way of our patients being our North Star. By any objective measure, our ability to hire qualified staff, deliver outstanding – best-in-class – patient care, and innovate for the betterment of people living with kidney disease far outpaces the industry. This is evidenced by the fact that the most recently available CMS (Centers for Medicare & Medicaid Services) 5-Star quality data, which concluded that more than 65% of all Fresenius Kidney Care (FKC) dialysis centers received 3 stars or higher – higher than the combined national average of all U.S. dialysis providers. Our approximately 70,000 employees and care teams, working across more than 2,600 dialysis centers, and delivering over 31 million treatments annually in the U.S. take immense pride in providing best-in-class, high-quality care to our patients. And our ability to introduce revolutionary advancements and innovation in kidney care, including the upcoming introduction of the 5008X™ CAREsystem in the U.S. that will deliver high-volume hemodiafiltration starting later in 2025, demonstrates our unwavering focus on improving quality of life, strengthening clinical outcomes, and extending the lifespan of those we have the privilege to serve.
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