International Study of Health Care Organization and Financing of renal services in England and Wales

Payment systems for dialysis and their effects: a scoping review

BACKGROUND

End stage renal disease (ESRD) is a major health concern and a large drain on healthcare resources. A wide range of payment methods are used for management of ESRD. The main aim of this study is to identify current payment methods for dialysis and their effects.

METHOD

In this scoping review Pubmed, Scopus, and Google Scholar were searched from 2000 until 2021 using appropriate search strategies. Retrieved articles were screened according to predefined inclusion criteria. Data about the study characteristics and study results were extracted by a pre-structured data extraction form; and were analyzed by a thematic analysis approach.

RESULTS

Fifty-nine articles were included, the majority of them were published after 2011 (66%); all of them were from high and upper middle-income countries, especially USA (64% of papers). Fee for services, global budget, capitation (bundled) payments, and pay for performance (P4P) were the main reimbursement methods for dialysis centers; and FFS, salary, and capitation were the main methods to reimburse the nephrologists. Countries have usually used a combination of methods depending on their situations; and their methods have been further developed over time specially from the retrospective payment systems (RPS) towards the prospective payment systems (PPS) and pay for performance methods. The main effects of the RPS were undertreatment of unpaid and inexpensive services, and over treatment of payable services. The main effects of the PPS were cost saving, shifting the service cost outside the bundle, change in quality of care, risk of provider, and modality choice.

CONCLUSION

This study provides useful insights about the current payment systems for dialysis and the effects of each payment system; that might be helpful for improving the quality and efficiency of healthcare.

Effect of a Pay-for-Performance Program on Renal Outcomes Among Patients With Early-Stage Chronic Kidney Disease in Taiwan

BACKGROUND

With the promising outcomes of the pre-ESRD (end-stage renal disease) pay-for-performance (P4P) program, the National Health Insurance Administration (NHIA) of Taiwan launched a P4P program for patients with early chronic kidney disease (CKD) in 2011, targeting CKD patients at stages 1, 2, and 3a. This study aimed to examine the long-term effect of the early-CKD P4P program on CKD progression.

METHODS

We conducted a matched cohort study using electronic medical records from a large healthcare delivery system in Taiwan. The outcome of interest was CKD progression to estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m2 between P4P program enrolees and non-enrolees. The difference in the cumulative incidence of CKD progression between the P4P and non-P4P groups was tested using Gray's test. We adopted a cause-specific (CS) hazard model to estimate the hazard in the P4P group as compared to non-P4P group, adjusting for age, sex, baseline renal function, and comorbidities. A subgroup analysis was further performed in CKD patients with diabetes to evaluate the interactive effects between the early-CKD P4P and diabetes P4P programs.

RESULTS

The incidence per 100 person-months of disease progression was significantly lower in the P4P group than in the non-P4P group (0.44 vs. 0.69, P<.0001), and the CS hazard ratio (CS-HR) for P4P program enrolees compared with non-enrolees was 0.61 (95% CI: 0.58-0.64, P<.0001). The results of the subgroup analysis further revealed an additive effect of the diabetes P4P program on CKD progression; compared to none of both P4P enrolees, the CS-HR for CKD disease progression was 0.60 (95% CI: 0.54-0.67, P<.0001) for patients who were enrolled in both early-CKD P4P and diabetes P4P programs.

CONCLUSION

The present study results suggest that the early-CKD P4P program is superior to usual care to decelerate CKD progression in patients with early-stage CKD.

Provision and quality of dialysis services in Libya

Dialysis is entirely funded by the public health care sector in Libya. Access to treatment is unrestricted for citizens but there is a lack of local information and no renal registry to gather national data. This cross-sectional study aimed to investigate dialysis provision and practice in Libyan dialysis facilities in 2009. A structured interview regarding dialysis capacity, staffing and methods of assessment of dialysis patients, and infection control measures was conducted with the medical directors of all 40 dialysis centers and 28 centers were visited. A total of 2417 adult patients were receiving maintenance dialysis in 40 centers, giving a population prevalence of approximately 624 per million. Most dialysis units were located in the northern part of the country and only 12.5% were free-standing units. Only three centers offered peritoneal dialysis. One hundred ninety-two hemodialysis rooms hosted 713 functioning hemodialysis stations, giving a ratio of one machine to 3.4 patients. Around half of centers operated only two dialysis shifts per day. Nephrologist/internist to patient ratio was 1:40 and nurse to patient ratio was 1:3.7. We found a wide variation in monitoring of dialysis patients, with dialysis adequacy assessed only in a minority. Separate rooms were allocated for chronic viral infection seropositive patients in 92.5% of the units. In general, the provision of dialysis is adequate but several areas for improvement have been identified, including a need for implementation of guidelines, recruitment of more nephrologists, and the development of more cost-effective alternatives such as peritoneal dialysis and transplantation.

International trends in erythropoietin use and hemoglobin levels in hemodialysis patients

Hemoglobin levels and the dose of erythropoiesis-stimulating agents (ESAs) have risen over time in hemodialysis patients within the United States. There are concerns that these trends may be driven by reimbursement policies that provide potential incentives to increase this use. To determine this we studied trends in the use of ESA and hemoglobin levels in hemodialysis patients and the relationship of these trends to the mode of reimbursement. Using the Dialysis Outcomes and Practice Patterns Study (DOPPS) database of hemodialysis we analyzed facility practices in over 300 randomly selected dialysis units in 12 countries. At each of three phases (years 1996-2001, 2002-2004, and 2005-present), we randomly selected over 7500 prevalent hemodialysis, hemofiltration, or hemodiafiltration patients. ESA usage rose significantly in every country studied except Belgium. All but Sweden demonstrated a substantial increase in hemoglobin levels. In 2005 more than 40% of patients had hemoglobin levels above the KDOQI upper target limit of 120 g/l in all but Japan. These trends appeared to be independent of the manner of reimbursement even though the United States is the only country with significant financial incentives promoting increased use of these agents. Thus, our study found that prescribing higher doses of ESAs and achieving higher hemoglobin levels by physicians reflects a broad trend across DOPPS countries regardless of the reimbursement policies.

The cost-effectiveness of induction immunosuppression in kidney transplantation

BACKGROUND

Induction immunosuppression is perceived as an expensive therapy, so is often given only to select patients. This study evaluated the cost-effectiveness of antibody induction comparing interleukin-2 receptor antagonists (IL2Ra) to standard therapy with no induction or induction with polyclonal antibodies.

METHODS

A Markov model was developed to estimate costs and health outcomes [survival (life years saved, LYS) and quality-adjusted survival (QALYs)] for the alternative strategies. Outcome data were obtained from a meta-analysis of randomized trials and large-scale renal registries.

RESULTS

IL2Ra offers improved survival of 0.21 LYS (2.5 months) and 1.42 QALYs compared with no induction, with a cost saving over 20 years of $79,302 per patient treated regardless of risk profile. The incremental benefits of IL2Ra compared with polyclonal antibody induction therapy were 0.35 LYS (4.3 months) and 0.20 QALYs, with an incremental cost of $5144 per patient. The incremental cost-effectiveness ratio (ICER) of IL2Ra compared to polyclonal induction was $14,803 per LYS and $25,928 per QALY. Sensitivity analyses showed that IL2Ra remained more effective and less expensive than no induction. When IL2Ra was compared to polyclonal induction, the model was sensitive to changes in the cost of induction and the probability of malignancy. Over the range of all other variables tested, IL2Ra was cost-effective compared to polyclonal induction.

CONCLUSIONS

Adopting IL2Ra as induction immunosuppression for kidney transplant recipients improves survival and QALYs and is less costly than no induction. It also represents good value for money compared to polyclonal induction.

The financing and organization of medical care for patients with end-stage renal disease in Sweden

The total health care expenditure as a percentage of the gross domestic product in Sweden is 9.2%, and health care is funded by global budgets almost entirely through general taxation. The prevalence rate of end-stage renal disease (ESRD) in Sweden is 756 per million. Fifty-two percent of ESRD patients have a functioning transplant. Almost all ESRD treatment facilities are public. Compared with other Dialysis Outcomes and Practice Patterns Study (DOPPS) countries, the salaries for both nephrologists and professional dialysis unit staff are low. Sweden's high cost per ESRD patient, relative to other DOPPS countries, may be a result of expensive and frequent hospitalizations and aggressive anemia treatment strategies.

Belgium's mixed private/public health care system and its impact on the cost of end-stage renal disease

Belgium has a mixed, public-private health care system, with state-organized reimbursements but private providers. The system is fee for service. For end-stage renal disease (ESRD), the fee-for-service system discourages preventive strategies, early referral to the nephrology unit, and the use of home-based therapies. The aging of the general population is reflected in the rapidly increasing number of very old dialysis patients, requiring more complicated and, therefore, more costly care. As dialysis costs increase, the ability to provide unrestricted access to dialysis treatment may be unsustainable. To aid in decision-making processes, nephrologists must be aware of financial and organizational issues.

International study of health care organization and financing: development of renal replacement therapy in Germany

The German health system represents the case of a global budget with negotiated fees and competing medical insurance companies. Physicians in private practice and non-profit dialysis provider associations provide most dialysis therapy. End-stage renal disease (ESRD) modalities are well integrated into the overall health care system. Dialysis therapy, independent of the mode of treatment, is reimbursed at a weekly flat rate. Mandatory health insurance covers health expenses, including those related to ESRD, for more than 90% of the population. Both employees and employers contribute to the premium for this insurance. Private medical insurance covers the remainder of the population. Access to treatment, including dialysis therapy, is uniformly available.

International Study of Health Care Organization and Financing for end-stage renal disease in France

The major features of ESRD management in France include the predominance of hemodialysis and the resulting competition for dialysis stations. In 2003, the prevalence of ESRD in France was 0.087%. Of the 52,000 ESRD patients, 30,882 were receiving dialysis and 21,233 had functioning renal transplants. The annual expenditure per ESRD patient in 2003 was estimated at euro40,975. Autodialysis, at euro49,133 per patient per year, was much less expensive than dialyzing in-center at either a public or private facility (euro111,006 and euro75,125, respectively). Transplant activity in France has rapidly increased in recent years, reaching 22 donors per million population in 2005.

End-stage renal disease and economic incentives: the International Study of Health Care Organization and Financing (ISHCOF)

End-stage renal disease (ESRD) is a debilitating, costly, and increasingly common condition. Little is known about how different financing approaches affect ESRD outcomes and delivery of care. This paper presents results from a comparative review of 12 countries with alternative models of incentives and benefits, collected under the International Study of Health Care Organization and Financing, a substudy within the Dialysis Outcomes and Practice Patterns Study. Variation in spending per ESRD patient is relatively small, but correlated with overall per capita health care spending. Remaining differences in costs and outcomes do not seem strongly linked to differences in incentives.