In an effort to improve outcomes at the nation's 6,000 dialysis facilities, Medicare plans to cut reimbursement rates up to 2% if the facilities perform poorly on an expanded set of quality metrics.
Despite pushback from providers on existing metrics, used only to rate facilities, a study highlighted “a massive fail” in achieving high performance on at least one key metric considered the standard of care for more than 20 years. “It makes me think there's something wrong with the system,” said Dr. Mahmoud Malas, author of a JAMA Surgery report on regional variation in quality for end-stage renal disease care.
Researchers and patient advocates say a number of systemic challenges limit providers' ability to deliver higher-quality care to end-stage renal disease (ESRD) patients. They include misaligned reimbursement incentives that still reward providers despite substandard care and a failure to address factors that prevent patients from following dietary guidelines or routinely showing up for treatments.
“The biggest concern for patients is, 'Can I work?' and 'Can I eat?' ” said Lori Hartwell, a former dialysis patient and founder of the not-for-profit patient advocacy group Renal Support Network. “There is not enough evidence for measures that could be truly meaningful from a patient's perspective.”
More broadly, there's concern over the nation's failure to address issues that are filling the pipeline with new dialysis patients, most of whom reach the end stage of chronic kidney disease only after years of poorly controlled hypertension and diabetes.
Poor coordination between primary-care doctors, nephrologists and vascular surgeons often leads to a failure to detect early signs of kidney disease, which would enable providers to get patients on a trajectory to avoid dialysis. “It's not one particular specialty,” said Malas, director of endovascular surgery at the Johns Hopkins Bayview Medical Center, Baltimore. “We are all responsible for this failure.”
Since the 1970s, Medicare has paid the bill for treating ESRD patients. Nearly 489,000 patients were in the agency's ESRD program in 2010, according to the U.S. Renal Data System, at a cost of $32.9 billion.
Patients with renal failure experience a depressing lifestyle change. Without a transplant, patients require dialysis to filter toxins from their body three times a week for the rest of their lives. Each treatment lasts about four hours. Transplanted kidneys could end dialysis, but only 17,105 kidney transplants occurred in the U.S. in 2014, according to the National Kidney Foundation.
Despite paying an average of $88,000 annually per patient, the mortality rate among dialysis patients is 7.4 times higher than the general population. The U.S. has one of the worst dialysis survival rates in the world. According to an analysis in the Journal of the American Society of Nephrology, 21.7% of U.S. dialysis patients die every year compared with 6.6% in Japan and 15.6% in Europe.