Denise Speicher, a fair-skinned, middle-aged woman with a big smile, seems sturdy and healthy. But three times a week, she makes a 20-minute trip to HighlandHospital, where she receives 3 1/2 hours of hemodialysis. The process cleans the toxins from her blood. Without it, Speicher would die within a couple of weeks.

Speicher was born with one kidney. She underwent two transplants, but both failed, and she has been coping with chronic kidney disease for most of her life. Yet she considers herself lucky; she has a supportive family and for 25 years has worked for "a wonderful employer."

"They've been through everything with me," says Speicher.

Speicher is both a dialysis patient and a patient advocate. And she isn't hesitant about weighing in on changes that have occurred in some local dialysis units. Those changes, Speicher and some dialysis-unit staffmembers say, have affected patients. And they have triggered a contentious labor dispute.

Four years ago, the dialysis operations at Strong Memorial and HighlandHospitals were sold to New York Dialysis Services, a unit of German-owned Fresenius Medical Care AG, which makes dialysis equipment. NYDS has sites near New York City, and locally, it operates dialysis sites at Strong, Highland, Clinton Crossing Medical Campus in Brighton, the HighlandsLivingCenter in Pittsford, and a unit in Victor. It's not the only game in town for dialysis patients, but it is the major player.

The change from a Strong facility to the for-profit NYDS has made life harder for patients, says Speicher. She says she believes her center is short-staffed, and she's concerned about staff training. Some experienced staffmembers have left since NYDS took over the units, she says.

And Speicher says there've been other changes, problems that are not as significant as staff shortages but that make the dialysis experience less comfortable. NYDS has stopped providing ice to relieve the thirst that patients sometimes experience, for instance, says Speicher, and blankets are no longer provided for patients who feel chilled by the dialysis process. The company has stopped offering a particular type of bandage that some patients prefer.

Some NYDS workers share Speicher's concerns. Last spring and fall, dialysis nurses, technicians, dieticians, social workers, and some administrative support staff voted to organize in two bargaining units under Local 1199 of the Service Employees International Union. The union has been negotiating with NYDS for months but hasn't been able to get a contract, and the ongoing tension has strained the work environment, union leaders say.

Dialysis patients live challenging lives under the best of conditions. It's hard for people to fully appreciate patients' situation, says Dan Newhouse, events and special projects coordinator with the National Kidney Foundation of Upstate New York. Kidney disease "is not a temporary condition," says Newhouse. "It's like having a part-time job just to survive."

And, says Newhouse, the relationship between the patients and dialysis-unit staff is an important one. "You're with these people for 12 to 18 hours a week, and you develop a relationship with them that is different than it is for other types of medical care," he says. "The psychological factors are high, because you're dependent on this treatment and these people for life. It's not like you have an operation, go home, and get better."

Most people can survive on one fully functioning kidney. But when both kidneys fail, patients are in a life-threatening state, because the blood is building up harmful wastes and excess fluids. The body is literally poisoning itself.

The common remedy is hemodialysis. Patients are hooked up to a dialysis machine --- a wonder of hospital technology larger than most office copiers --- through needles and tubing. Their blood is then sent to the dialysis machine, where filters clean it and slowly route it back to the body.

Newhouse describes dialysis-unit employees as the foundation of the unit. "They're the ones who really see what you're going through," he says, "and they make all the difference in the world in how you feel."

"It's hard work," says Newhouse. "They deserve a contract, and I believe they deserve good wages."

SEIU members say they unionized in response to short staffing and lack of adequate supplies. At first, they say, NYDS responded with management and staffing changes and also agreed to a formal grievance process. But, says Bruce Popper, regional vice president for SEIU: "Their tone changed dramatically when they saw the wages and benefits being proposed. They put the brakes on contract negotiations, making themselves unavailable for weeks at a time."

Pay equity has been the biggest stumbling block. The demand for health-care workers has increased, forcing companies to pay more to attract employees. As a result, some new employees at NYDS units are earning more than employees with more experience.

"We have a nurse with six or seven years of experience who is being paid $3 an hour less than a new hire with no experience," says Popper. "We have a tech with four years of dialysis experience making $10.30 an hour while he trains new hires with no experience making $1.70 an hour more. That's not fair pay. We want a written pay scale that credits experience."

"We want an additional 5 percent for nurses and techs that are nationally certified," says Popper. "These are people who have gone for extra training above and beyond minimum requirements." The union also wants reimbursement for work-related conferences and continuing education.

Adequate staffing continues to be a concern, says Popper. "Last summer was a nightmare," he says, "and they had to float people from other areas." Things were better in the fall, he says, "but we had an RN just this morning that is on a mandatory 16-hour shift."

"All we're asking for," says Popper, "is a patient care committee where the non-supervisory staff can meet on a regular basis, and if this problem is coming up because the workload has changed, we can bring it to their attention."

In April of this year, a federal mediator, Kenneth Armes, entered the labor talks between SEIU and NYDS.

"This is an initial contract for the Rochester group, and many of the issues have changed for that area in the last two years," says Val Riley, regional vice president for NYDS. "It is very expensive to run this type of facility. We have just brought in 60 new employees, new management, and new training systems. And this is a very technology-driven business. We have to stay ahead of it, and technology changes in a nano-second."

As the conflict has dragged on, tensions among the staff have built. Some employees have begun to try to get the union dissolved. Popper says management has deliberately dragged its heels in negotiations, trying to discourage union members and bring about the collapse of the union.

"These are some of the same tactics they used in New York City and DutchessCounty, but they didn't work, "says Popper. "There's overwhelming support for the union, and they know it."

NYDS's management disagrees. Employees, says Riley, want to decertify the union. "The professional group which includes the nurses, dieticians, and social workers will be presenting a petition on June 8 to decertify," says Riley. "The workers feel they [SEIU] are no longer representing the members; they are only representing themselves and their best interests. Now they're engaged in a smear campaign against the company, and that's too bad."

Dieticians seem to be one group siding with management. "I've been a part of the negotiating team, and we have never wanted to be a part of the union," says Anne Jozwiak, a registered dietician with NYDS. "All of the dieticians signed the petition saying we didn't want to be part of it. And there are a lot of us in other departments who feel this way."

Jozwiak says she joined the negotiating team so that she and others opposed to the union would be represented in the contract talks.

Says an employee in the tech-equipment area, who asked not to be identified: "I was for the union at first, but now it seems they have their own agenda. This is a new management team, and they have turned this company around 360 degrees. There were a lot of staffing problems and cost cutting, but that has changed."

On May 19, about 20 members of the SEIU --- NYSD nurses, techs, and secretaries wearing purple and yellow SEIU T-shirts --- were picketing in front of the Clinton Crossings location. It was an unusual sight in an otherwise drab business park, with picketers sometimes met with shouts of support or opposition from passing cars.

"I worked at Strong for 29 years until NYDS took over," said Cathy Witkousky, an RN. "We all came from a background where you really cared about your patients. These people are profits first, so a lot of the more experienced employees have left. I took a cut in benefits to keep this job. I love my patients and their families. I didn't want to abandon them now."

"This is a technical job that is always changing," said Witkousky. "You have to keep up in order to stay certified in this specialty. They don't assist with certification. If you had someone coming at you with a needle, wouldn't you like to know how well trained they are?"

"In some cases, we have been so short staffed that the nurses don't even have time to give input to the tech," said Witkousky.

Speicher agrees: "You get accustomed to the staff. When you have so much turnover, you don't know what they're going to be like. There are two needles with this machine, and a bunch of tubes. It's an anxiety that you don't need on a regular basis."

And, she says, patients who are unhappy can't simply change dialysis providers. "Changing units is not that easy," says Speicher. "You have to see if the other facility can fit you in. If you work, there's that schedule to consider. It takes a lot of juggling, and some patients feel it may not be worth it."

Significantly, Strong sold its dialysis unit to NYDS "because the cost of buying and maintaining dialysis equipment has become prohibitive," says hospital spokesperson Teri D'Agostino. And for all health-care consumers, the dialysis-unit experience is instructive.

"This is part of a trend," says D'Agostino, "where you will see hospitals divesting themselves from operations like this, and companies that specialize in it buying them up." Strong has had no complaints from NYDS patients regarding deteriorating services, says D'Agostino, and state law requires NYDS to address patient complaints.

And NYDS spokesperson Val Riley insists that patients are the company's top priority. "We are committed to and focused on giving patients good care," she says.

"I don't think it has anything to do with whether the company is for-profit or a not-for-profit," says Jan Miller, executive director for the National Kidney Foundation of Upstate New York. While she would not comment on the contract negotiations with NYDS, she did say that concerns over costs and services related to chronic kidney disease are not likely to change any time soon.

Today, 20 million Americans --- one out of every nine adults --- have chronic kidney disease, and according to the National Kidney Foundation, many of them don't even know they have it.

"The diabetes epidemic in this country has caused the number of [kidney disease] cases to rise dramatically in the last few years," Miller says. "It is the Number 1 cause of kidney disease. There are 270 people on the kidney transplant waiting list at Strong. Only 70 were performed there last year."

"The waiting time for an organ transplant is up to five years," says Miller. "Ten years ago, it was only one year. You can see the trend. And you can see that the demand for dialysis is growing all across the country."

And some observers say the situation in Rochester may be a bellwether for specialized health care all across the country, as an aging population that is more prone to chronic disease deals with higher costs for care.