New York, NY, October 11, 2018 – Is Medicare driving late-stage chronic kidney disease patients to dialysis prematurely because it does not pay for comprehensive, non-dialysis care within the offices of nephrologists? Three researchers have concluded that it is time to reform the federal payment system.
Dr. Jeffrey S. Berns, MD, Professor of Medicine and Pediatrics at the Perelman School of Medicine at the University of Pennsylvania; Dr. Eugene Lin, MD, MS, Assistant Professor of Medicine at the Keck School of Medicine of the University of Southern California; and Tonya Saffer, Vice President of Health Policy at the National Kidney Foundation have co-authored an editorial for the Journal of the American Society of Nephrology titled “Addressing Financial Disincentives to Improve CKD Care.” View the online posting of the editorial here.
The Centers for Medicare & Medicaid Services (CMS) pays 80 percent of the cost of dialysis for most patients in the United States. One patient on dialysis costs the federal program about $88,000 annually and the cost is rising. Nephrologists who oversee patients on dialysis are paid substantially more through a monthly capitated payment (MCP) under Medicare for overseeing the care of each patient they see.
However, doctors who treat late-stage, non-dialysis patients, are not equally resourced by Medicare or private payers, creating a financial incentive for providers to focus most of their attention on patients receiving dialysis.
“In general, providers favor fee-for-service over monthly capitation payments,” according to Dr. Lin. “It’s the disparity between the MCP for dialysis and fee-for-service payment for evaluation and management of CKD patients that drives this poor incentive.”
“Caring for patients with CKD not on dialysis requires a multi-pronged approach to delay progression of CKD for as long as possible while helping patients that do progress to ESRD make informed decisions about their treatment options, including home dialysis and transplantation, and ease transitions of care. Most nephrologists do not have the supports in their offices to deliver that needed comprehensive care to non-dialysis patients,” Dr. Berns said.
Dialysis centers, on the other hand, are financially resourced by Medicare for the infrastructure needed to tackle the many comorbidities associated with ESRD, while physicians’ offices are not.
“The payment disparity could create an adverse incentive for nephrologist to recommend starting dialysis early, even when it might not be necessary or in the patients’ best interest,” the researchers wrote in the Journal.
In their opinion paper, the researchers call for reform in the payment structure of Medicare for CKD patients.
“We are suggesting a pilot program that reforms nephrologist payments for advanced CKD patients not on dialysis that pays nephrologists more in alignment with the MCP they receive for dialysis care, but that also holds them accountable for costs and quality,” Saffer said. “We believe this will reduce expenditures to Medicare due to delayed progression, avoidance of hospitalizations, and better ESRD starts.
They offer one possible service structure that could be required and monitored for CKD care that includes:
- Face-to-face office visits or telehealth services to manage certain comorbidities;
- Dietitian services;
- Pharmacy services and medication reconciliation;
- Care coordination with primary care providers and other specialists;
- Screening for depression and anxiety;
- Access to social services;
- Recommended immunization;
- CKD, dialysis modality and transplant education;
- Advance care planning with palliative/conservative care coordination if indicated;
- Vascular or peritoneal dialysis access placement;
- Transplant evaluation
- Outpatient dialysis initiation when appropriate.
“A pilot program would also allow CMS to determine the feasibility of these programs in different types of nephrology practices,” they wrote. “Given the disproportionate share of ESRD costs in Medicare, a trial with Medicare patients seems justifiable, although such an approach could easily be undertaken by other payers.”
The Journal of the American Society of Nephrology is the official publication of the American Society of Nephrology.
About Kidney Disease
In the United States, 30 million adults are estimated to have chronic kidney disease—and most aren’t aware of it. 1 in 3 American adults are at risk for chronic kidney disease. Risk factors for kidney disease include diabetes, high blood pressure, heart disease, obesity, and family history. People of African American, Hispanic, Native American, Asian, or Pacific Islander descent are at increased risk for developing the disease. African Americans are 3 times more likely than Whites, and Hispanics are nearly 1.5 times more likely than non-Hispanics to develop end stage renal disease (kidney failure).
The National Kidney Foundation (NKF) is the largest, most comprehensive and longstanding organization dedicated to the awareness, prevention and treatment of kidney disease. For more information about the NKF visit www.kidney.org.