Changes in Medicare Reimbursement and Patient-Nephrologist Visits, Quality of Care, and Health-Related Quality of Life

Mentari, Evelyn; DeOreo, Peter B.; O’Connor, Andrew; Love, Thomas E.; Ricanati, Edmond S.; Sehgal, Ashwini R.

doi:10.1053/j.ajkd.2005.06.012

Cited by 34 publications

(47 citation statements)

References 18 publications

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“…On average, in 2010, CMS reimbursed providers 72% more on a per-patient basis if the patient was seen four times per month relative to if a patient was seen one time per month (9). A survey of dialysis facilities suggested that providers responded promptly to this economic incentive (10)(11)(12)(13). The amount of geographic variation in visit frequency after this economic incentive was introduced has not been described.…”

Section: Introductionmentioning

confidence: 99%

Variation in Nephrologist Visits to Patients on Hemodialysis across Dialysis Facilities and Geographic Locations

Erickson

Tan

Winkelmayer

et al. 2013

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives Geographic and other variations in medical practices lead to differences in medical costs, often without a clear link to health outcomes. This work examined variation in the frequency of physician visits to patients receiving hemodialysis to measure the relative importance of provider practice patterns (including those patterns linked to geographic region) and patient health in determining visit frequency.Design, setting, participants, & measurements This work analyzed a nationally representative 2006 database of patients receiving hemodialysis in the United States. A variation decomposition analysis of the relative importance of facility, geographic region, and patient characteristics-including demographics, socioeconomic status, and indicators of health status-in explaining physician visit frequency variation was conducted. Finally, the associations between facility, geographic and patient characteristics, and provider visit frequency were measured using multivariable regression.Results Patient characteristics accounted for only 0.9% of the total visit frequency variation. Accounting for casemix differences, patients' hemodialysis facilities explained about 24.9% of visit frequency variation, of which 9.3% was explained by geographic region. Visit frequency was more closely associated with many facility and geographic characteristics than indicators of health status. More recent dialysis initiation and recent hospitalization were associated with decreased visit frequency.Conclusions In hemodialysis, provider visit frequency depends more on geography and facility location and characteristics than patients' health status or acuity of illness. The magnitude of variation unrelated to patient health suggests that provider visit frequency practices do not reflect optimal management of patients on dialysis.

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Section: Introductionmentioning

confidence: 99%

Variation in Nephrologist Visits to Patients on Hemodialysis across Dialysis Facilities and Geographic Locations

Erickson

Tan

Winkelmayer

et al. 2013

Clinical Journal of the American Society of Nephrology

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“…26 Although more frequent visits do not appear to improve health outcomes in the majority of patients on hemodialysis, [24][25][26] there may be specific groups of patients who benefit from closer monitoring. We previously demonstrated that patients recently discharged from the hospital benefit from more frequent visits through fewer rehospitalizations and reduced healthcare costs.…”

Section: Discussionmentioning

confidence: 99%

“…A regional survey of 12 dialysis facilities found that although physician visit frequency increased briskly in response to the reimbursement policy, health outcomes did not improve. 25 Another study examining the association between visit frequency and health outcomes at a national level in the period Data are expressed as percentages unless otherwise indicated. The third quartile ranges from three and one-half visits to four visits, whereas the fourth quartile is entirely composed of four visits per month.…”

Section: Discussionmentioning

confidence: 99%

Provider Visits and Early Vascular Access Placement in Maintenance Hemodialysis

Erickson

Mell

Winkelmayer

et al. 2015

Journal of the American Society of Nephrology

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Medicare reimbursement policy encourages frequent provider visits for patients with ESRD undergoing hemodialysis. We hypothesize that patients seen more frequently by their nephrologist or advanced practitioner within the first 90 days of hemodialysis are more likely to undergo surgery to create an arteriovenous (AV) fistula or place an AV graft. We selected 35,959 patients aged $67 years starting hemodialysis in the United States from a national registry. We used multivariable regression to evaluate the associations between mean visit frequency and AV fistula creation or graft placement in the first 90 days of hemodialysis. We conducted an instrumental variable analysis to test the sensitivity of our findings to potential bias from unobserved characteristics. One additional visit per month in the first 90 days of hemodialysis was associated with a 21% increase in the odds of AV fistula creation or graft placement during that period (95% confidence interval, 19% to 24%), corresponding to an average 4.5% increase in absolute probability. An instrumental variable analysis demonstrated similar findings. Excluding visits in months when patients were hospitalized, one additional visit per month was associated with a 10% increase in odds of vascular access surgery (95% confidence interval, 8% to 13%). In conclusion, patients seen more frequently by care providers in the first 90 days of hemodialysis undergo earlier AV fistula creation or graft placement. Payment policies that encourage more frequent visits to patients at key clinical time points may yield more favorable health outcomes than policies that operate irrespective of patients' health status.

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“…Mentari and colleagues evaluated changes in quality of care and health-related quality of life before and after the rule went into effect and found that patient visits increased from 1.5 to 3.14 (P,0.001) and the percentage of patients not seen during the month decreased from 16.6% to 5.1% (P,0.001); however, there were no differences in Kt/V, albumin, hemoglobin, phosphorus, calcium, catheter use, hospitalizations, compliance with dialysis treatment prescription, or patient satisfaction (5). Using a larger national sample of data from the US Renal Data System (USRDS), Slinin and colleagues evaluated provider-patient visit frequency and hemodialysis outcomes, and found no difference in all-cause mortality; however, patients who had four provider visits per month had a 4% lower risk of first hospitalization, or hospitalizations for congestive heart failure, cardiovascular disease, infection, or vascular access compared with those with less frequent visits (6).…”

mentioning

confidence: 96%

Geography and ESRD Care

Young

2013

Clinical Journal of the American Society of Nephrology

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In 2004, the Centers for Medicare and Medicaid Services (CMS) made a landmark change in the way nephrologists were reimbursed for outpatient dialysis visits for the first time in over 30 years. The Final Rule, as it was called, changed reimbursement for dialysis outpatient assessment from a capitated monthly visit to a graded reimbursement based on the number of times per month a patient was seen in the outpatient setting. These ESRD-related visits, defined by the new "G codes," allow for reimbursement for 1 visit, 2-3 visits, or $4 visits per month. Visits must be provided face to face by a nephrologist or other provider and can occur in the dialysis unit or other outpatient settings (1). Before the Final Rule, much discussion occurred among dialysis providers, nephrologists, and nephrology practices because of concerns that acceptance of this rule would have adverse effects on ESRD patient care due to increased requirements for dialysis unit rounding.Before the ruling, little was known regarding the association of frequency of dialysis rounding and outcomes. Several observational studies reported that increased frequency of dialysis patient visits by nephrologists was associated with several positive outcomes, including achievement of some clinical performance targets (albumin and dialysis adequacy [Kt/V], and total number of improved performance measures) (2), satisfaction with the nephrologist, and patient adherence (3). However, increased frequency was not associated with improved short-term outcomes such as fewer hospitalizations, better quality of life, or overall satisfaction with care (3). Conversely, increased frequency of "sit-down" team rounds with nursing staff, social workers, and nutritionists in the dialysis unit was associated with better clinical performance measures (albumin level), fewer hospitalizations (incidence rate ratio, 0.68; 95% confidence interval [95% CI], 0.51 to 0.91), decreased number of hospital days, and improved survival (hazard ratio, 0.71; 95% CI, 0.53 to 0.95) compared with units with fewer reported sit-down team rounds (4).Since the Final Rule went into effect, recent studies have evaluated the association of dialysis patient visits and outcomes. Mentari and colleagues evaluated changes in quality of care and health-related quality of life before and after the rule went into effect and found that patient visits increased from 1.5 to 3.14 (P,0.001) and the percentage of patients not seen during the month decreased from 16.6% to 5.1% (P,0.001); however, there were no differences in Kt/V, albumin, hemoglobin, phosphorus, calcium, catheter use, hospitalizations, compliance with dialysis treatment prescription, or patient satisfaction (5). Using a larger national sample of data from the US Renal Data System (USRDS), Slinin and colleagues evaluated provider-patient visit frequency and hemodialysis outcomes, and found no difference in all-cause mortality; however, patients who had four provider visits per month had a 4% lower risk of first hospitalization, or hospitalizations for...

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Changes in Medicare Reimbursement and Patient-Nephrologist Visits, Quality of Care, and Health-Related Quality of Life

Cited by 34 publications

References 18 publications

Variation in Nephrologist Visits to Patients on Hemodialysis across Dialysis Facilities and Geographic Locations

Variation in Nephrologist Visits to Patients on Hemodialysis across Dialysis Facilities and Geographic Locations

Provider Visits and Early Vascular Access Placement in Maintenance Hemodialysis

Geography and ESRD Care

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