Kidney Failure and the Federal Government (1991) / Chapter Skim
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PART I Overview This part of the report includes the Summary and Chapter 1. The former summarizes the report and presents the recommendations of the committee.
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program thus established has been very successful, saving several hundred thousand Americans from premature death and giving hope to individuals who once faced certain death. At present, over 150,000 ESRD patients receive Medicare services, including inpatient and outpatient care, from both physicians and treatment units, for dialysis, kidney transplantation, and other medical services.
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The IOM committee, therefore, endorses the following objectives for the Medicare ESRD program: to guarantee access to treatment for allfor whom it is medically appropriate; to provide care of high quality that achieves desirable health outcomes consistent with patient health status and current professional knowledge; to develop policies that steadily improve patient well-being and patient outcomes; and to manage the program prudently at the lowest cost compatible with adequate care.
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The major diseases causing kidney failure are glomerulonephritis, diabetes, and hypertension. The proportion of ESRD patients with a primary diagnosis of diabetes mellitus increased from about 13 percent in 1980 to 24 percent in 1988; this diagnosis accounted for 31 percent of all new patients in 1988.
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The Department of Veterans Affairs dialysis program is shrinking, the Indian Health Service faces many other demands on its limited resources, and the 19 state kidney disease programs have benefits that vary and budgets that are not increasing. State Medicaid programs, therefore, represent the only payer for many ESRD patients who are not eligible for Medicare.
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However, the committee does not believe that access to life-saving dialysis and transplantation should depend on the precise number of ESRD patients not eligible for Medicare. Limiting Medicare ESRD eligibility to those with Social Security insured status places some excluded persons at risk of death.
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Although several studies suggest that only a fraction of suitable kidneys is made available for renal transplantation, the extent of the gap between potential and actual donors is unclear and effective ways to close this gap are not well understood. When coupled with the rapid annual increase in new ESRD patients, the shortage of kidneys means that dialysis will continue to be the predominant form of ESRD treatment.
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Guidelines should be developed specifically for children and should describe the role of the parents in the decision-making process. Nephrologists and other clinicians should discuss with all ESRD patients their wishes about dialysis, cardiopulmonary resuscitation, and other life-sustaining treatments and encourage documented advance directives.
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Independent rather than hospital-based units accounted for most of the growth in outpatient dialysis facilities. They now account for 70 percent of all dialysis stations.
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First, reimbursement rates for outpatient dialysis, in real dollars, have steadily decreased over the 18-year history of the ESRD program, due both to a fixed rate (from 1973 to 1983) that was never adjusted for inflation as well as to explicit rate reductions in 1983 and 1986.
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However, the emphasis on the effect of the 1983 composite rate on mortality may be inappropriate. The changing patient population has been mentioned above, as has the effect of clinical opinion on shorter treatment time.
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These professionals are currently responsible for very large numbers of patients; for example, staff-to-patient ratios of 1 to 100 and 1 to 200, respectively, exist in many dialysis units. Consequently, social workers and dietitians may have been reduced to fulfilling minimal routine functions rather than the essential social or nutrition counseling considered optimal for patient care.
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Data strongly suggest that decreased reimbursement has led to decreased staffing in dialysis units, to shifts from nurses to technicians, and to important reductions in social worker and dietitian staffing. Although there is no evidence that these changes in staffing patterns have affected quality, professional opinion favors this contention.
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Outpatient Dialysis Reimbursement Issues The committee addressed the implications for dialysis reimbursement policy of the information about (1) the effect of reimbursement on quality of care and (2)
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Nominally, reimbursement rates for dialysis are based on the audited costs of providers. In fact, the rate-setting process for dialysis facilities, unlike that for the hospital sector under prospective payment, has made no provision for updating rates to reflect the effects of inflation on costs during the time between the year when cost data are collected and the adoption of a new rate.
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It recommends, therefore, that ProPAC, which has been mandated to review ambulatory care, also review rate-setting in the ESRD program.7 In addition, the committee recommends that HCFA establish an expert committee to advise it on potential additions to the "bundle of services" needed for dialysis patients as innovations arise and clinical practice changes. Given a patient population of increasing complexity, suggestive but not conclusive evidence of the erosion of quality, the absence of a system to monitor quality, and the life-saving nature of dialysis treatment, the committee recommends that Congress and HCFA adopt the following payment policies for dialysis facilities: Do not reduce the composite rate at this time.
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Adopt the following specific ESRD reimbursement policies: 1. Evaluate the justification for the rate differential between hospital-based and independent facilities, especially in terms of patient complexity, and retain or eliminate the differential based on that analysis.
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Also discussed is the use of continuous quality improvement, which focuses on improving patient management at the treatment-unit level. The report presents three examples of providers using some of these modern QA methods.
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for establishing the USRDS, and UNOS for its new data system. In the coming decade, HCFA should address itself to these needs: improving data on primary diagnosis of renal failure, including data on insulin-dependent and non-insulin-dependent diabetes mellitus; developing overall measures of patient complexity, including the extent and severity of comorbid conditions; developing measures of functional and health status and other short-term outcomes; collecting information on ESRD patients who are not eligible for Medicare coverage; obtaining better ethnic data on ESRD patients, including those of Hispanic origin; and measuring patient mortality in the first three months of treatment (before Medicare eligibility is established)
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The committee commends NIDDK for this action. The committee recommends that USRDS be authorized to conduct research linking epidemiologic and economic data on the ESRD patient population and that the special studies approach be exploited to its full potential.
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1987. Effects of the 1983 "Composite Rate" Changes on ESRD Patients, Providers, and Spending.
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