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Wang V, Swaminathan S, Corneau EA, Maciejewski ML, Trivedi AN, O'Hare AM, Mor V. Association of VA Payment Reform for Dialysis with Spending, Access to Care, and Outcomes for Veterans with ESKD. Clin J Am Soc Nephrol 2020; 15:1631-1639. [PMID: 32963019 PMCID: PMC7646236 DOI: 10.2215/cjn.02100220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 08/13/2020] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Virginia Wang
- Center of Innovation for Health Services Research, Durham Veterans Affairs Health Care System, Durham, North Carolina .,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Shailender Swaminathan
- Center of Innovation for Long Term Services and Supports, Providence Veterans Affairs Health Care System, Providence, Rhode Island.,Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
| | - Emily A Corneau
- Center of Innovation for Long Term Services and Supports, Providence Veterans Affairs Health Care System, Providence, Rhode Island
| | - Matthew L Maciejewski
- Center of Innovation for Health Services Research, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Amal N Trivedi
- Center of Innovation for Long Term Services and Supports, Providence Veterans Affairs Health Care System, Providence, Rhode Island.,Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
| | - Ann M O'Hare
- Center for Health Services Research in Older Adults, Puget Sound Health Care System, Seattle, Washington.,Department of Medicine, University of Washington, Seattle, Washington
| | - Vincent Mor
- Center of Innovation for Long Term Services and Supports, Providence Veterans Affairs Health Care System, Providence, Rhode Island.,Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
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Wang V, Coffman CJ, Stechuchak KM, Berkowitz TSZ, Hebert PL, Edelman D, O'Hare AM, Crowley ST, Weidenbacher HJ, Maciejewski ML. Survival among Veterans Obtaining Dialysis in VA and Non-VA Settings. J Am Soc Nephrol 2018; 30:159-168. [PMID: 30530657 DOI: 10.1681/asn.2018050521] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 10/17/2018] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Virginia Wang
- Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina; .,Department of Population Health Sciences.,Division of General Internal Medicine, Department of Medicine, and
| | - Cynthia J Coffman
- Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Karen M Stechuchak
- Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Theodore S Z Berkowitz
- Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Paul L Hebert
- Center for Health Services Research in Older Adults, Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, School of Public Health and
| | - David Edelman
- Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Division of General Internal Medicine, Department of Medicine, and
| | - Ann M O'Hare
- Center for Health Services Research in Older Adults, Puget Sound Health Care System, Seattle, Washington.,Department of Medicine, University of Washington, Seattle, Washington
| | - Susan T Crowley
- Renal Section, Medical Services, Veterans Affairs Connecticut Health Care System, West Haven, Connecticut; and.,Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Hollis J Weidenbacher
- Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Matthew L Maciejewski
- Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Department of Population Health Sciences.,Division of General Internal Medicine, Department of Medicine, and
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Navaneethan SD, Akeroyd JM, Ramsey D, Ahmed ST, Mishra SR, Petersen LA, Muntner P, Ballantyne C, Winkelmayer WC, Ramanathan V, Virani SS. Facility-Level Variations in Kidney Disease Care among Veterans with Diabetes and CKD. Clin J Am Soc Nephrol 2018; 13:1842-1850. [PMID: 30498000 PMCID: PMC6302320 DOI: 10.2215/cjn.03830318] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 09/01/2018] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
| | - Julia M. Akeroyd
- Section of Health Services Research, and
- Health Policy, Quality and Informatics Program, Health Services Research and Development Center for Innovations, and
| | - David Ramsey
- Center for Longitudinal and Lifecourse Research, Faculty of Medicine, University of Queensland, Brisbane, Australia; and
| | - Sarah T. Ahmed
- Health Policy, Quality and Informatics Program, Health Services Research and Development Center for Innovations, and
| | - Shiva Raj Mishra
- Center for Longitudinal and Lifecourse Research, Faculty of Medicine, University of Queensland, Brisbane, Australia; and
| | - Laura A. Petersen
- Health Policy, Quality and Informatics Program, Health Services Research and Development Center for Innovations, and
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Christie Ballantyne
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | | | - Venkat Ramanathan
- Selzman Institute for Kidney Health, Section of Nephrology
- Section of Nephrology
| | - Salim S. Virani
- Section of Health Services Research, and
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Health Policy, Quality and Informatics Program, Health Services Research and Development Center for Innovations, and
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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Kourany W, Crowley ST. Site of Care and Health Outcomes of Veterans Undergoing Maintenance Dialysis. Clin J Am Soc Nephrol 2018; 13:979-981. [PMID: 29903899 PMCID: PMC6032580 DOI: 10.2215/cjn.06100518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/14/2023]
Affiliation(s)
- Wissam Kourany
- Section of Nephrology, Department of Medicine, Duke University, Durham, North Carolina
- Section of Nephrology, Department of Medicine, Veterans Affairs Durham Healthcare System, Durham, North Carolina
| | - Susan T. Crowley
- Section of Nephrology, Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut; and
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
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