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Tummalapalli SL, Mendu ML. Value-Based Care and Kidney Disease: Emergence and Future Opportunities. Adv Chronic Kidney Dis 2022; 29:30-39. [PMID: 35690401 PMCID: PMC9199582 DOI: 10.1053/j.ackd.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/16/2021] [Accepted: 10/05/2021] [Indexed: 01/03/2023]
Abstract
The United States health care system has increasingly embraced value-based programs that reward improved outcomes and lower costs. Health care value, defined as quality per unit cost, was a major goal of the 2010 Patient Protection and Affordable Care Act amid high and rising US health care expenditures. Many early value-based programs were specifically designed for patients with end-stage renal disease (ESRD) and targeted toward dialysis facilities, including the ESRD Prospective Payment System, ESRD Quality Incentive Program, and ESRD Seamless Care Organizations. While a great deal of attention has been paid to these ESRD-focused programs, other value-based programs targeted toward hospitals and health systems may also affect the quality and costs of care for a broader population of patients with kidney disease. Value-based care for kidney disease is increasingly relevant in light of the Advancing American Kidney Health initiative, which introduces new value-based payment models: the mandatory ESRD Treatment Choices Model in 2021 and voluntary Kidney Care Choices Model in 2022. In this review article, we summarize the emergence and impact of value-based programs on the quality and costs of kidney care, with a focus on federal programs. Key opportunities in value-based kidney care include shifting the focus toward chronic kidney disease, enhancing population health management capabilities, improving quality measurement, and leveraging programs to advance health equity.
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Affiliation(s)
- Sri Lekha Tummalapalli
- Division of Healthcare Delivery Science & Innovation, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY,The Rogosin Institute, New York, NY
| | - Mallika L. Mendu
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA,Center for Population Health, Mass General Brigham, Boston, MA
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2
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Powers BW, Yan J, Zhu J, Linn KA, Jain SH, Kowalski J, Navathe AS. The Beneficial Effects Of Medicare Advantage Special Needs Plans For Patients With End-Stage Renal Disease. Health Aff (Millwood) 2021; 39:1486-1494. [PMID: 32897788 DOI: 10.1377/hlthaff.2019.01793] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Patients with end-stage renal disease (ESRD) are a vulnerable population with high rates of morbidity, mortality, and acute care use. Medicare Advantage Special Needs Plans (SNPs) are an alternative financing and delivery model designed to improve care and reduce costs for patients with ESRD, but little is known about their impact. We used detailed clinical, demographic, and claims data to identify fee-for-service Medicare beneficiaries who switched to ESRD SNPs offered by a single health plan (SNP enrollees) and similar beneficiaries who remained enrolled in fee-for-service Medicare plans (fee-for-service controls). We then compared three-year mortality and twelve-month utilization rates. Compared with fee-for-service controls, SNP enrollees had lower mortality and lower rates of utilization across the care continuum. These findings suggest that SNPs may be an effective alternative care financing and delivery model for patients with ESRD.
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Affiliation(s)
- Brian W Powers
- Brian W. Powers is deputy chief medical officer at Humana in Boston, Massachusetts
| | - Jiali Yan
- Jiali Yan is a data analyst in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, in Philadelphia, Pennsylvania
| | - Jingsan Zhu
- Jingsan Zhu is assistant director of data analytics in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Kristin A Linn
- Kristin A. Linn is an assistant professor of biostatistics in the Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania
| | - Sachin H Jain
- Sachin H. Jain is president and CEO, SCAN Group and Health Plan, and an adjunct professor of medicine, Stanford University School of Medicine, in Stanford, California
| | - Jennifer Kowalski
- Jennifer Kowalski is vice president of the Anthem Public Policy Institute, in Washington, D.C
| | - Amol S Navathe
- Amol S. Navathe is a core investigator at the Corporal Michael J. Cresencz Veterans Affairs Medical Center; an assistant professor in the Department of Medical Ethics and Health Policy, Perelman School of Medicine; and a senior fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania, all in Philadelphia
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3
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Awan AA, Erickson KF. ACOs and Bending the Cost Curve for Health Care Spending for People with Kidney Failure. Clin J Am Soc Nephrol 2020; 15:1699-1701. [PMID: 33234542 PMCID: PMC7769026 DOI: 10.2215/cjn.16521020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Ahmed A. Awan
- Department of Medicine, Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Kevin F. Erickson
- Department of Medicine, Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas
- Baker Institute for Public Policy, Rice University, Houston, Texas
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4
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Bakre S, Hollingsworth JM, Yan PL, Lawton EJ, Hirth RA, Shahinian VB. Accountable Care Organizations and Spending for Patients Undergoing Long-Term Dialysis. Clin J Am Soc Nephrol 2020; 15:1777-1784. [PMID: 33234541 PMCID: PMC7769034 DOI: 10.2215/cjn.02150220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 10/02/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Despite representing 1% of the population, beneficiaries on long-term dialysis account for over 7% of Medicare's fee-for-service spending. Because of their focus on care coordination, Accountable Care Organizations may be an effective model to reduce spending inefficiencies for this population. We analyzed Medicare data to examine time trends in long-term dialysis beneficiary alignment to Accountable Care Organizations and differences in spending for those who were Accountable Care Organization aligned versus nonaligned. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this retrospective cohort study, beneficiaries on long-term dialysis between 2009 and 2016 were identified using a 20% random sample of Medicare beneficiaries. Trends in alignment to an Accountable Care Organization were compared with alignment of the general Medicare population from 2012 to 2016. Using an interrupted time series approach, we examined the association between Accountable Care Organization alignment and the primary outcome of total spending for long-term dialysis beneficiaries from prior to Accountable Care Organization implementation (2009-2011) through implementation of the Comprehensive ESRD Care model in October 2015. We fit linear regression models with generalized estimating equations to adjust for patient characteristics. RESULTS During the study period, 135,152 beneficiaries on long-term dialysis were identified. The percentage of long-term dialysis beneficiaries aligned to an Accountable Care Organization increased from 6% to 23% from 2012 to 2016. In the time series analysis, spending on Accountable Care Organization-aligned beneficiaries was $143 (95% confidence interval, $5 to $282) less per beneficiary-quarter than spending for nonaligned beneficiaries. In analyses stratified by whether beneficiaries received care from a primary care physician, savings by Accountable Care Organization-aligned beneficiaries were limited to those with care by a primary care physician ($235; 95% confidence interval, $73 to $397). CONCLUSIONS There was a substantial increase in the percentage of long-term dialysis beneficiaries aligned to an Accountable Care Organization from 2012 to 2016. Moreover, in adjusted models, Accountable Care Organization alignment was associated with modest cost savings among long-term dialysis beneficiaries with care by a primary care physician.
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Affiliation(s)
- Shivani Bakre
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - John M Hollingsworth
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Phyllis L Yan
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Emily J Lawton
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Richard A Hirth
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Vahakn B Shahinian
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan .,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan.,Kidney Epidemiology and Cost Center, University of Michigan School of Public Health, Ann Arbor, Michigan
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5
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Al Salmi I, Larkina M, Wang M, Subramanian L, Morgenstern H, Jacobson SH, Hakim R, Tentori F, Saran R, Akiba T, Tomilina NA, Port FK, Robinson BM, Pisoni RL. Missed Hemodialysis Treatments: International Variation, Predictors, and Outcomes in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2018; 72:634-643. [PMID: 30146421 DOI: 10.1053/j.ajkd.2018.04.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 04/26/2018] [Indexed: 02/08/2023]
Abstract
RATIONALE & OBJECTIVE Missed hemodialysis (HD) treatments not due to hospitalization have been associated with poor clinical outcomes and related in part to treatment nonadherence. Using data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) phase 5 (2012-2015), we report findings from an international investigation of missed treatments among patients prescribed thrice-weekly HD. STUDY DESIGN Prospective observational study. SETTING & PARTICIPANTS 8,501 patients participating in DOPPS, on HD therapy for more than 120 days, from 20 countries. Longitudinal and cross-sectional analyses were performed based on the 4,493 patients from countries in which 4-month missed treatment risk was > 5%. PREDICTORS The main predictor of patient outcomes was 1 or more missed treatments in the 4 months before DOPPS phase 5 enrollment; predictors of missed treatments included country, patient characteristics, and clinical factors. OUTCOMES Mortality, hospitalization, laboratory measures, patient-reported outcomes, and 4-month missed treatment risk. ANALYTICAL APPROACH Outcomes were assessed using Cox proportional hazards, logistic, and linear regression, adjusting for case-mix and country. RESULTS The 4-month missed treatment risk varied more than 50-fold across all 20 DOPPS countries, ranging from < 1% in Italy and Japan to 24% in the United States. Missed treatments were more likely with younger age, less time on dialysis therapy, shorter HD treatment time, lower Kt/V, longer travel time to HD centers, and more symptoms of depression. Missed treatments were positively associated with all-cause mortality (HR, 1.68; 95% CI, 1.37-2.05), cardiovascular mortality, sudden death/cardiac arrest, hospitalization, serum phosphorus level > 5.5mg/dL, parathyroid hormone level > 300pg/mL, hemoglobin level < 10g/dL, higher kidney disease burden, and worse general and mental health. LIMITATIONS Possible residual confounding; temporal ambiguity in the cross-sectional analyses. CONCLUSIONS In the countries with a 4-month missed treatment risk > 5%, HD patients were more likely to die, be hospitalized, and have poorer patient-reported outcomes and laboratory measures when 1 or more missed treatments occurred in a 4-month period. The large variation in missed treatments across 20 nations suggests that their occurrence is potentially modifiable, especially in the United States and other countries in which missed treatment risk is high.
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Affiliation(s)
| | - Maria Larkina
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | - Mia Wang
- University of Michigan, Ann Arbor, MI
| | | | - Hal Morgenstern
- Department of Epidemiology, Medical School, University of Michigan, Ann Arbor, MI; Department of Environmental Health Sciences, Medical School, University of Michigan, Ann Arbor, MI; School of Public Health, and Department of Urology, Medical School, University of Michigan, Ann Arbor, MI
| | | | | | - Francesca Tentori
- Arbor Research Collaborative for Health, Ann Arbor, MI; Vanderbilt University, Nashville, TN
| | | | | | | | - Friedrich K Port
- Arbor Research Collaborative for Health, Ann Arbor, MI; University of Michigan, Ann Arbor, MI
| | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI; University of Michigan, Ann Arbor, MI
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Thorsteinsdottir B, Ramar P, Hickson LJ, Reinalda MS, Albright RC, Tilburt JC, Williams AW, Takahashi PY, Jeffery MM, Shah ND. Care of the dialysis patient: Primary provider involvement and resource utilization patterns - a cohort study. BMC Nephrol 2017; 18:322. [PMID: 29070040 PMCID: PMC5657054 DOI: 10.1186/s12882-017-0728-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 09/29/2017] [Indexed: 01/21/2023] Open
Abstract
Background Efficient and safe delivery of care to dialysis patients is essential. Concerns have been raised regarding the ability of accountable care organizations to adequately serve this high-risk population. Little is known about primary care involvement in the care of dialysis patients. This study sought to describe the extent of primary care provider (PCP) involvement in the care of hemodialysis patients and the outcomes associated with that involvement. Methods In a retrospective cohort study, patients accessing a Midwestern dialysis network from 2001 to 2010 linked to United States Renal Database System and with >90 days follow up were identified (n = 2985). Outpatient visits were identified using Current Procedural Terminology (CPT)-4 codes, provider specialty, and grouped into quartiles-based on proportion of PCP visits per person-year (ppy). Top and bottom quartiles represented patients with high primary care (HPC) or low primary care (LPC), respectively. Patient characteristics and health care utilization were measured and compared across patient groups. Results Dialysis patients had an overall average of 4.5 PCP visits ppy, ranging from 0.6 in the LPC group to 6.9 in the HPC group. HPC patients were more likely female (43.4% vs. 35.3%), older (64.0 yrs. vs. 60.0 yrs), and with more comorbidities (Charlson 7.0 vs 6.0). HPC patients had higher utilization (hospitalizations 2.2 vs. 1.8 ppy; emergency department visits 1.6 vs 1.2 ppy) and worse survival (3.9 vs 4.3 yrs) and transplant rates (16.3 vs. 31.5). Conclusions PCPs are significantly involved in the care of hemodialysis patients. Patients with HPC are older, sicker, and utilize more resources than those managed primarily by nephrologists. After adjusting for confounders, there is no difference in outcomes between the groups. Further studies are needed to better understand whether there is causal impact of primary care involvement on patient survival. Electronic supplementary material The online version of this article (10.1186/s12882-017-0728-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bjorg Thorsteinsdottir
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. .,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, 55905, USA. .,Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, 55905, USA.
| | - Priya Ramar
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, 55905, USA
| | - LaTonya J Hickson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, 55905, USA.,Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Megan S Reinalda
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, 55905, USA
| | - Robert C Albright
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Jon C Tilburt
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, 55905, USA.,Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Amy W Williams
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Paul Y Takahashi
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Molly M Jeffery
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Nilay D Shah
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, 55905, USA
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7
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Kalantar-Zadeh K, Kovesdy CP, Streja E, Rhee CM, Soohoo M, Chen JL, Molnar MZ, Obi Y, Gillen D, Nguyen DV, Norris KC, Sim JJ, Jacobsen SS. Transition of care from pre-dialysis prelude to renal replacement therapy: the blueprints of emerging research in advanced chronic kidney disease. Nephrol Dial Transplant 2017; 32:ii91-ii98. [PMID: 28201698 PMCID: PMC5837675 DOI: 10.1093/ndt/gfw357] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 09/06/2016] [Indexed: 12/11/2022] Open
Abstract
In patients with advanced (estimated glomerular filtration rate <25 mL/min/1.73 m2) non-dialysis-dependent chronic kidney disease (CKD) the optimal transition of care to renal replacement therapy (RRT), i.e. dialysis or transplantation, is not known. Mortality and hospitalization risk are extremely high upon transition and in the first months following the transition to dialysis. Major knowledge gaps persist pertaining to differential or individualized transitions across different demographics and clinical measures during the 'prelude' period prior to the transition, particularly in several key areas: (i) the best timing for RRT transition; (ii) the optimal RRT type (dialysis versus transplant), and in the case of dialysis, the best modality (hemodialysis versus peritoneal dialysis), format (in-center versus home), frequency (infrequent versus thrice-weekly versus more frequent) and vascular access preparation; (iii) the post-RRT impact of pre-RRT prelude conditions and events such as blood pressure and glycemic control, acute kidney injury episodes, and management of CKD-specific conditions such as anemia and mineral disorders; and (iv) the impact of the above prelude conditions on end-of-life care and RRT decision-making versus conservative management of CKD. Given the enormous changes occurring in the global CKD healthcare landscape, as well as the high costs of transitioning to dialysis therapy with persistently poor outcomes, there is an urgent need to answer these important questions. This review describes the key concepts and questions related to the emerging field of 'Transition of Care in CKD', systematically defines six main categories of CKD transition, and reviews approaches to data linkage and novel prelude analyses along with clinical applications of these studies.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
- VA Long Beach Healthcare System, Long Beach, CA, USA
- Los Angeles Biomedical Research Institute, Harbor-UCLA Med. Center, Torrance, CA, USA
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
- VA Long Beach Healthcare System, Long Beach, CA, USA
| | - Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
- VA Long Beach Healthcare System, Long Beach, CA, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | | | - Miklos Z. Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Daniel Gillen
- University of California Irvine Program for Public Health, Irvine, CA, USA
| | - Danh V. Nguyen
- General Internal Medicine, University of California Irvine Medical Center, Orange, CA, USA
- Biostatistics, Epidemiology and Research Design, University of California Irvine, Irvine, CA, USA
| | - Keith C. Norris
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - John J. Sim
- Kaiser Permanente of Southern California, Pasadena, CA, USA
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Fuller DS, Robinson BM. Facility Practice Variation to Help Understand the Effects of Public Policy: Insights from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Clin J Am Soc Nephrol 2017; 12:190-199. [PMID: 28062678 PMCID: PMC5220653 DOI: 10.2215/cjn.03930416] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Recent Centers for Medicare & Medicaid Services policies have used dialysis facility practice variation to develop public ratings and adjust payments. In the Dialysis Facility Compare star rating system (DFC SRS), facility-relative rates of performance-based clinical measures varied nearly two-fold for mortality (standardized mortality ratio; 10th/90th percentiles: 0.71, 1.34) and hospitalization (standardized hospitalization ratio; 10th/90th percentiles: 0.64, 1.37), and nearly four-fold for transfusion (standardized transfusion ratio; 10th/90th percentiles: 0.43, 1.65). Medicare claims data (from July of 2014) demonstrate that facility variation for the proportions of patients on hemodialysis hospitalized (10th/90th percentiles: 27%, 50%) and transfused (10th/90th percentiles: 3%, 17%) within 6 months that far exceeds relatively modest recent overall longitudinal trends. DFC SRS-rated facility variation is also substantial for fistula (10th/90th percentiles: 50%, 78%) and catheter use >90 days (10th/90th percentiles: 3%, 19%). By contrast, DFC SRS-rated facility distributions for adult hemodialysis Kt/V>1.2 (10th/90th percentiles: 84%, 97%) and total serum calcium >10.2 mg/dl (median, 1%; 75th/90th percentiles: 3%, 5%) are quite narrow and may be of questionable value. Likewise, variation in the US Dialysis Outcomes and Practice Patterns Study is over two-fold for facility median serum parathyroid hormone (10th/90th percentiles: 290 pg/ml, 629 pg/ml) and ferritin (10th/90th percentiles: 469 ng/ml, 1143 ng/ml) levels, and facility mean treatment time varies by 30 minutes (10th/90th percentiles: 204 minutes, 234 minutes). Rising serum parathyroid hormone and ferritin levels, and generally short dialysis treatment time, represent areas unchecked by existing policy; both overall trends and facility variation in these values may reflect unintended consequences of policy or reimbursement pressures and therefore raise concern. Additionally, outcomes in the transition period from advanced CKD to dialysis remain poor, and policy initiatives and performance accountability in this area remain insufficient. Innovative models of comprehensive care in advanced CKD and the early dialysis period which are more amenable to policy oversight are needed. In summary, facility variation is typically larger than prevailing longitudinal trends, and should not be overlooked. The combination of nationally representative observational databases (e.g., the Dialysis Outcomes and Practice Patterns Study) and ESRD registries can provide policy makers with additional tools to evaluate facility variation, develop policies, and monitor unintended effects.
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Affiliation(s)
| | - Bruce M. Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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9
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Seibert E, Richter A, Kuhlmann MK, Wang S, Levin NW, Kotanko P, Handelman GJ. Plasma vitamin C levels in ESRD patients and occurrence of hypochromic erythrocytes. Hemodial Int 2016; 21:250-255. [PMID: 27619554 DOI: 10.1111/hdi.12467] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 07/19/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The achievement of erythropoiesis in hemodialysis (HD) patients is typically managed with erythropoiesis-stimulating-agents (ESA's) and intravenous iron (IV-iron). Using this treatment strategy, HD patients frequently show an elevated fraction of red blood cells (RBC) with hemoglobin (Hb) content per cell that is below the normal range, called hypochromic RBC. The low Hb content per RBC is the result of the clinical challenge of providing sufficient iron content to the bone marrow during erythropoiesis. Vitamin C supplements have been used to increase Hb levels in HD patients with refractory anemia, which supports the hypothesis that vitamin C mobilizes iron needed for Hb synthesis. METHODS We conducted a cross-sectional survey in 149 prevalent HD patients of the percent hypochromic RBC, defined as RBC with Hb < 300 ng/uL of packed RBC, in relation to plasma vitamin C levels. We also measured high-sensitivity CRP, (hs-CRP), iron, and ferritin levels. and calculated ESA dose. FINDINGS High plasma levels of vitamin C were negatively associated with hypochromic RBC (P < 0.003), and high ESA doses were positively associated (P < 0.001). There was no significant association of hs-CRP with percent hypochromic RBC. DISCUSSION This finding supports the hypothesis that vitamin C mobilizes iron stores, improves iron delivery to the bone marrow, and increase the fraction of RBC with normal Hb content. Further research is warranted on development of protocols for safe and effective use of supplemental vitamin C for management of renal anemia.
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Affiliation(s)
- Eric Seibert
- Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | | | | | - Suxin Wang
- University of Massachusetts, Lowell, Massachusetts, USA
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10
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Canaud B, Blankestijn PJ, Davenport A, Bots ML. Reconciling and Closing the Loop Between Evidence-Based and Practice-Based Medicine: The Case for Hemodiafiltration. Am J Kidney Dis 2016; 68:176-179. [PMID: 27477357 DOI: 10.1053/j.ajkd.2016.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 05/10/2016] [Indexed: 12/25/2022]
Affiliation(s)
| | | | - Andrew Davenport
- University College London, Royal Free Hospital, London, United Kingdom
| | - Michiel L Bots
- University Medical Center Utrecht, Utrecht, the Netherlands
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11
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Nissenson AR. Delivering Better Quality of Care: Relentless Focus and Starting with the End in Mind at DaVita. Semin Dial 2016; 29:111-8. [DOI: 10.1111/sdi.12462] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Allen R. Nissenson
- Office of the Chief Medical Officer; DaVita Healthcare Partners Inc.; El Segundo California
- Department of Medicine; David Geffen School of Medicine at UCLA; Los Angeles California
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12
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Yan G, Cheung AK, Greene T, Yu AJ, Oliver MN, Yu W, Ma JZ, Norris KC. Interstate Variation in Receipt of Nephrologist Care in US Patients Approaching ESRD: Race, Age, and State Characteristics. Clin J Am Soc Nephrol 2015; 10:1979-88. [PMID: 26450930 DOI: 10.2215/cjn.02800315] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 07/13/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Although multiple factors influence access to nephrologist care in patients with CKD stages 4-5, the geographic determinants within the United States are incompletely understood. In this study, we examined interstate differences in nephrologist care among patients approaching ESRD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This national, population-based analysis included 373,986 adult patients from the US Renal Data System, who initiated maintenance dialysis between 2005 and 2009. Multilevel logistic regression was used to examine interstate variation in nephrologist care (≥12 months before ESRD) for overall and four race-age subpopulations (black or white and older or younger than 65 years). RESULTS The average state-level probability of having received nephrologist care in all states combined was 28.8% (95% confidence interval, 25.2% to 32.7%) overall and was lowest (24.3%) in the younger black subpopulation. Even at these lower levels, state-level probabilities varied considerably across states in overall and subpopulations (all P<0.001). Overall, excluding the states in the upper and lower five percentiles, the remaining states had a probability of receiving care that varied from 18.5% to 41.9%. The lower probability of receiving nephrologist care for blacks than whites among younger patients noted in most states was attenuated in older patients. Geographically, all New England states and most Midwest states had higher than average probability, whereas most Middle Atlantic and Southern states had lower than average probability. After controlling for patient factors, three state-characteristic categories, including general healthcare access measured by percentage of uninsured persons and Medicaid program performance scores, preventive care measured by percentage of receiving recommended preventive care, and socioeconomic status, contributed 55%-66% of interstate variation. CONCLUSIONS Patients living in states with better health service and socioeconomic characteristics were more likely to receive predialysis nephrologist care. The reported national black-white difference in nephrologist care was primarily driven by younger black patients being the least likely to receive care.
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Affiliation(s)
- Guofen Yan
- Departments of Public Health Sciences and
| | - Alfred K Cheung
- Divisions of Nephrology and Hypertension and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Tom Greene
- Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Alison J Yu
- Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - M Norman Oliver
- Family Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Wei Yu
- Departments of Public Health Sciences and
| | | | - Keith C Norris
- Department of Medicine, Geffen School of Medicine, University of California, Los Angeles, California
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Nicholas SB, Kalantar-Zadeh K, Norris KC. Socioeconomic disparities in chronic kidney disease. Adv Chronic Kidney Dis 2015; 22:6-15. [PMID: 25573507 DOI: 10.1053/j.ackd.2014.07.002] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 07/11/2014] [Accepted: 07/16/2014] [Indexed: 01/13/2023]
Abstract
CKD is a national public health problem that afflicts persons of all segments of society. Although racial/ethnic disparities in advanced CKD including dialysis-dependent populations have been well established, the finding of differences in CKD incidence, prevalence, and progression across different socioeconomic groups and racial and ethnic strata has only recently started to receive significant attention. Socioeconomics may exert both interdependent and independent effects on CKD and its complications and may confound racial and ethnic disparities. Socioeconomic constellations influence not only access to quality care for CKD risk factors and CKD treatment but may mediate many of the cultural and environmental determinants of health that are becoming more widely recognized as affecting complex medical disorders. In this article, we have reviewed the available literature pertaining to the role of socioeconomic status and economic factors in both non-dialysis-dependent CKD and ESRD. Advancing our understanding of the role of socioeconomic factors in patients with or at risk for CKD can lead to improved strategies for disease prevention and management.
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DeCamp M, Farber NJ, Torke AM, George M, Berger Z, Keirns CC, Kaldjian LC. Ethical challenges for accountable care organizations: a structured review. J Gen Intern Med 2014; 29:1392-9. [PMID: 24664441 PMCID: PMC4175644 DOI: 10.1007/s11606-014-2833-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 01/21/2014] [Accepted: 03/02/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND Accountable care organizations (ACOs) are proliferating as a solution to the cost crisis in American health care, and already involve as many as 31 million patients. ACOs hold clinicians, group practices, and in many circumstances hospitals financially accountable for reducing expenditures and improving their patients' health outcomes. The structure of health care affects the ethical issues arising in the practice of medicine; therefore, like all health care organizational structures, ACOs will experience ethical challenges. No framework exists to assist key ACO stakeholders in identifying or managing these challenges. METHODS We conducted a structured review of the medical ACO literature using qualitative content analysis to inform identification of ethical challenges for ACOs. RESULTS Our analysis found infrequent discussion of ethics as an explicit concern for ACOs. Nonetheless, we identified nine critical ethical challenges, often described in other terms, for ACO stakeholders. Leaders could face challenges regarding fair resource allocation (e.g., about fairly using ACOs' shared savings), protection of professionals' ethical obligations (especially related to the design of financial incentives), and development of fair decision processes (e.g., ensuring that beneficiary representatives on the ACO board truly represent the ACO's patients). Clinicians could perceive threats to their professional autonomy (e.g., through cost control measures), a sense of dual or conflicted responsibility to their patients and the ACO, or competition with other clinicians. For patients, critical ethical challenges will include protecting their autonomy, ensuring privacy and confidentiality, and effectively engaging them with the ACO. DISCUSSION ACOs are not inherently more or less "ethical" than other health care payment models, such as fee-for-service or pure capitation. ACOs' nascent development and flexibility in design, however, present a time-sensitive opportunity to ensure their ethical operation, promote their success, and refine their design and implementation by identifying, managing, and conducting research into the ethical issues they might face.
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Affiliation(s)
- Matthew DeCamp
- Berman Institute of Bioethics and Division of General Internal Medicine, Johns Hopkins University, 1809 Ashland Avenue, Baltimore, MD, USA,
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15
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Talwalkar JA. Potential impacts of the Affordable Care Act on the clinical practice of hepatology. Hepatology 2014; 59:1681-7. [PMID: 24700278 DOI: 10.1002/hep.27071] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 01/24/2014] [Accepted: 02/11/2014] [Indexed: 01/18/2023]
Abstract
UNLABELLED The Patient Protection and Affordable Care Act (ACA), along with the Health Care and Education Reconciliation Act, was signed into law and upheld by the Supreme Court earlier this year. The ACA contains a variety of reforms that, if implemented, will significantly affect current models of healthcare delivery for patients with acute and chronic hepatobiliary diseases. One of the Act's central reforms is the creation of accountable care organizations (ACOs) whose mission will be to integrate different levels of care to improve the quality of services delivered and outcomes among populations while maintaining, or preferably reducing, the overall costs of care. Currently, there are clinical practice areas within hepatology, such as liver transplantation, that already have many of the desired features attributed to ACOs. The ACA is sure to affect all fields of medicine, including the practice of clinical hepatology. This article describes the components of the ACA that have the greatest potential to influence the clinical practice of hepatology. CONCLUSION Ultimately, it will be the responsibility of our profession to identify optimal healthcare delivery models for providing high-value, patient-centered care.
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Affiliation(s)
- Jayant A Talwalkar
- Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN; William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
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Weiner DE, Winkelmayer WC. Commentary on 'The DOPPS practice monitor for U.S. dialysis care: update on trends in anemia management 2 years into the bundle': iron(y) abounds 2 years later. Am J Kidney Dis 2014; 62:1217-20. [PMID: 24267389 DOI: 10.1053/j.ajkd.2013.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 10/09/2013] [Indexed: 11/11/2022]
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17
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Rubin RJ. Understanding Washington: A Nephrologist's Perspective From Inside the Beltway. Am J Kidney Dis 2013; 62:1042-5. [DOI: 10.1053/j.ajkd.2013.06.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 06/25/2013] [Indexed: 11/11/2022]
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18
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Nissenson AR. Improving outcomes for ESRD patients: shifting the quality paradigm. Clin J Am Soc Nephrol 2013; 9:430-4. [PMID: 24202130 DOI: 10.2215/cjn.05980613] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The availability of life-saving dialysis therapy has been one of the great successes of medicine in the past four decades. Over this time period, despite treatment of hundreds of thousands of patients, the overall quality of life for patients with ESRD has not substantially improved. A narrow focus by clinicians and regulators on basic indicators of care, like dialysis adequacy and anemia, has consumed time and resources but not resulted in significantly improved survival; also, frequent hospitalizations and dissatisfaction with the care experience continue to be seen. A new quality paradigm is needed to help guide clinicians, providers, and regulators to ensure that patients' lives are improved by the technically complex and costly therapy that they are receiving. This paradigm can be envisioned as a quality pyramid: the foundation is the basic indicators (outstanding performance on these indicators is necessary but not sufficient to drive the primary outcomes). Overall, these basics are being well managed currently, but there remains an excessive focus on them, largely because of publically reported data and regulatory requirements. With a strong foundation, it is now time to focus on the more complex intermediate clinical outcomes-fluid management, infection control, diabetes management, medication management, and end-of-life care among others. Successfully addressing these intermediate outcomes will drive improvements in the primary outcomes, better survival, fewer hospitalizations, better patient experience with the treatment, and ultimately, improved quality of life. By articulating this view of quality in the ESRD program (pushing up the quality pyramid), the discussion about quality is reframed, and also, clinicians can better target their facilities in the direction of regulatory oversight and requirements about quality. Clinicians owe it to their patients, as the ESRD program celebrates its 40th anniversary, to rekindle the aspirations of the creators of the program, whose primary goal was to improve the lives of the patients afflicted with this devastating condition.
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Affiliation(s)
- Allen R Nissenson
- David Geffen School of Medicine, University of California, Los Angeles, California
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Andersen MJ, Friedman AN. The coming fiscal crisis: nephrology in the line of fire. Clin J Am Soc Nephrol 2013; 8:1252-7. [PMID: 23704301 DOI: 10.2215/cjn.00790113] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Nephrologists in the United States face a very uncertain economic future. The astronomical federal debt and unfunded liability burden of Medicare combined with the aging population will place unprecedented strain on the health care sector. To address these fundamental problems, it is conceivable that the federal government will ultimately institute rationing and other budget-cutting measures to rein in costs of ESRD care, which is generously funded relative to other chronic illnesses. Therefore, nephrologists should expect implementation of cost-cutting measures, such age-based rationing, mandated delayed dialysis and home therapies, compensated organ donation, and a shift in research priorities from the dialysis to the predialysis patient population. Nephrologists also need to recognize that these changes, which are geared toward the population level, may make it more difficult to advocate effectively for the needs of individual patients.
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Affiliation(s)
- Martin J Andersen
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA.
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20
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Mollicone D, Pulliam J, Lacson Jr E. The Culture of Education in a Large Dialysis Organization: Informing Patient-Centered Decision Making on Treatment Options for Renal Replacement Therapy. Semin Dial 2013; 26:143-7. [DOI: 10.1111/sdi.12053] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hamm LL, Hostetter TH, Shaffer RN. Considering an integrated nephrology care delivery model: six principles for quality. Clin J Am Soc Nephrol 2012. [PMID: 23184568 DOI: 10.2215/cjn.04460512] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In 2012, 27 organizations will initiate participation in the Medicare Shared Savings Program as Accountable Care Organizations. This level of participation reflects the response of Centers for Medicare and Medicaid Services to criticism that the program as outlined in the proposed rule was overly burdensome, prescriptive, and too risky. Centers for Medicare and Medicaid Service made significant changes in the final rule, making the Accountable Care Organization program more attractive to these participants. However, none of these changes addressed the serious concerns raised by subspecialty societies-including the American Society of Nephrology-regarding care of patients with multiple chronic comorbidities and complex and end stage conditions. Virtually all of these concerns remain unaddressed, and consequently, Accountable Care Organizations will require guidance and partnership from the nephrology community to ensure that these patients are identified and receive the individualized care that they require. Although the final rule fell short of addressing the needs of patients with kidney disease, the Centers for Medicare and Medicaid Innovation presents an opportunity to test the potentially beneficial concepts of the Accountable Care Organization program within this patient population. The American Society of Nephrology Accountable Care Organization Task Force developed a set of principles that must be reflected in a possible pilot program or demonstration project of an integrated nephrology care delivery model. These principles include preserving a leadership role for nephrologists, encompassing care for patients with later-stage CKD and kidney transplants as well as ESRD, enabling the participation of a diversity of dialysis provider sizes and types, facilitating research, and establishing monitoring systems to identify and address preferential patient selection or changes in outcomes.
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Affiliation(s)
- L Lee Hamm
- Department of Medicine, School of Medicine, Tulane University, New Orleans, Louisiana, USA
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Robinson BM, Bieber B, Pisoni RL, Port FK. Dialysis Outcomes and Practice Patterns Study (DOPPS): its strengths, limitations, and role in informing practices and policies. Clin J Am Soc Nephrol 2012; 7:1897-905. [PMID: 23099654 DOI: 10.2215/cjn.04940512] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan 48104, USA.
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Krishnan M, Wilfehrt HM, Lacson E. In Data We Trust: The Role and Utility of Dialysis Provider Databases in the Policy Process. Clin J Am Soc Nephrol 2012; 7:1891-6. [DOI: 10.2215/cjn.03220312] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Williams AW, Nesse RE, Wood DL. Delivering accountable care to patients with complicated chronic illness: how does it fit into care models and do nephrologists have a role? Am J Kidney Dis 2012; 59:601-3. [PMID: 22507649 DOI: 10.1053/j.ajkd.2012.02.318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 02/13/2012] [Indexed: 11/11/2022]
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Watnick S, Weiner DE, Shaffer R, Inrig J, Moe S, Mehrotra R. Comparing mandated health care reforms: the Affordable Care Act, accountable care organizations, and the Medicare ESRD program. Clin J Am Soc Nephrol 2012; 7:1535-43. [PMID: 22626961 DOI: 10.2215/cjn.01220212] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In addition to extending health insurance coverage, the Affordable Care Act of 2010 aims to improve quality of care and contain costs. To this end, the act allowed introduction of bundled payments for a range of services, proposed the creation of accountable care organizations (ACOs), and established the Centers for Medicare and Medicaid Innovation to test new care delivery and payment models. The ACO program began April 1, 2012, along with demonstration projects for bundled payments for episodes of care in Medicaid. Yet even before many components of the Affordable Care Act are fully in place, the Medicare ESRD Program has instituted legislatively mandated changes for dialysis services that resemble many of these care delivery reform proposals. The ESRD program now operates under a fully bundled, case-mix adjusted prospective payment system and has implemented Medicare's first-ever mandatory pay-for-performance program: the ESRD Quality Incentive Program. As ACOs are developed, they may benefit from the nephrology community's experience with these relatively novel models of health care payment and delivery reform. Nephrologists are in a position to assure that the ACO development will benefit from the ESRD experience. This article reviews the new ESRD payment system and the Quality Incentive Program, comparing and contrasting them with ACOs. Better understanding of similarities and differences between the ESRD program and the ACO program will allow the nephrology community to have a more influential voice in shaping the future of health care delivery in the United States.
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