Delivering a "New Deal" of Kidney Health Opportunities to Improve Outcomes Within the Veterans Health Administration

Association of VA Payment Reform for Dialysis with Spending, Access to Care, and Outcomes for Veterans with ESKD

BACKGROUND AND OBJECTIVES

Because of the limited capacity of its own dialysis facilities, the Department of Veterans Affairs (VA) Veterans Health Administration routinely outsources dialysis care to community providers. Prior to 2011-when the VA implemented a process of standardizing payments and establishing national contracts for community-based dialysis care-payments to community providers were largely unregulated. This study examined the association of changes in the Department of Veterans Affairs payment policy for community dialysis with temporal trends in VA spending and veterans' access to dialysis care and mortality.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

An interrupted time series design and VA, Medicare, and US Renal Data System data were used to identify veterans who received VA-financed dialysis in community-based dialysis facilities before (2006-2008), during (2009-2010), and after the enactment of VA policies to standardize dialysis payments (2011-2016). We used multivariable, differential trend/intercept shift regression models to examine trends in average reimbursement for community-based dialysis, access to quality care (veterans' distance to community dialysis, number of community dialysis providers, and dialysis facility quality indicators), and 1-year mortality over this time period.

RESULTS

Before payment reform, the unadjusted average per-treatment reimbursement for non-VA dialysis care varied widely ($47-$1575). After payment reform, there was a 44% reduction ($44-$250) in the adjusted price per dialysis session (P<0.001) and less variation in payments for dialysis ($73-$663). Over the same time period, there was an increase in the number of community dialysis facilities contracting with VA to deliver care to veterans with ESKD from 19 to 37 facilities (per VA hospital), and there were no changes in either the quality of community dialysis facilities or crude 1-year mortality rate of veterans (12% versus 11%).

CONCLUSIONS

VA policies to standardize payment and establish national dialysis contracts increased the value of VA-financed community dialysis care by reducing reimbursement without compromising access to care or survival.

Survival among Veterans Obtaining Dialysis in VA and Non-VA Settings

BACKGROUND

Outcomes of veterans with ESRD may differ depending on where they receive dialysis and who finances this care, but little is known about variation in outcomes across different dialysis settings and financial arrangements.

METHODS

We examined survival among 27,241 Veterans Affairs (VA)-enrolled veterans who initiated chronic dialysis in 2008-2011 at (1) VA-based units, (2) community-based clinics through the Veterans Affairs Purchased Care program (VA-PC), (3) community-based clinics under Medicare, or (4) more than one of these settings ("dual" care). Using a Cox proportional hazards model, we compared all-cause mortality across dialysis settings during the 2-year period after dialysis initiation, adjusting for demographic and clinical characteristics.

RESULTS

Overall, 4% of patients received dialysis in VA, 11% under VA-PC, 67% under Medicare, and 18% in dual settings (nearly half receiving dual VA and VA-PC dialysis). Crude 2-year mortality was 25% for veterans receiving dialysis in the VA, 30% under VA-PC, 42% under Medicare, and 23% in dual settings. After adjustment, dialysis patients in VA or in dual settings had significantly lower 2-year mortality than those under Medicare; mortality did not differ in VA-PC and Medicare dialysis settings.

CONCLUSIONS

Mortality rates were highest for veterans receiving dialysis in Medicare or VA-PC settings and lowest for veterans receiving dialysis in the VA or dual settings. These findings inform institutional decisions about provision of dialysis for veterans. Further research identifying processes associated with improved survival for patients receiving VA-based dialysis may be useful in establishing best practices for outsourced veteran care.

Facility-Level Variations in Kidney Disease Care among Veterans with Diabetes and CKD

BACKGROUND AND OBJECTIVES

Facility-level variation has been reported among veterans receiving care for various diseases. We studied the frequency and facility-level variations of guideline-recommended practices in patients with diabetes and CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Patients with diabetes and concomitant CKD (eGFR 15-59 ml/min per 1.73 m2, measured twice, 90 days apart) receiving care in 130 facilities across the Veterans Affairs Health Care System were included (n=281,223). We studied the proportions of patients (facility-level) receiving recommended core measures and facility-level variations of these study outcomes using median rate ratios, adjusting for various patient and provider-level factors. Median rate ratio quantifies the degree to which care may vary for similar patients receiving care at two randomly chosen facilities, with <1 being no variation and >1.2 as substantial variation between the facilities. Study outcomes included measurement of urine albumin-to-creatinine ratio/urine protein-to-creatinine ratio and blood hemoglobin concentration, prescription of statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, BP<140/90 mm Hg, and referral to a Veterans Affairs nephrologist (only for those with eGFR<30 ml/min per 1.73 m2).

RESULTS

Among those with eGFR 30-59 ml/min per 1.73 m2, proportion of patients receiving recommended core measures (median and interquartile range across facilities) were 37% (22%-47%) for urine albumin-to-creatinine ratio/urine protein-to-creatinine ratio, 74% (72%-79%) for hemoglobin measurement, 66% (62%-69%) for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker prescription, 85% (74%-87%) for statin prescription, 47% (42%-53%) for achieving BP<140/90 mm Hg, and 13% (7%-16%) for meeting all outcome measures. Adjusted median rate ratios (95% confidence intervals) were 5.2 (4.1 to 6.4), 2.4 (2.1 to 2.6), 1.3 (1.2 to 1.3), 1.2 (1.2 to 1.3), 1.4 (1.3 to 1.4), and 4.1 (3.3 to 5.0), respectively. Median rate ratios were qualitatively similar in an analysis restricted to those with eGFR 15-29 ml/min per 1.73 m2.

CONCLUSIONS

Among patients with diabetes and CKD, at facility-level, ordering of laboratory tests, and scheduling of nephrology referrals in eligible patients remains suboptimal, with substantial variations across facilities.