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

https://doi.org/10.1053/j.ajkd.2005.06.012Get rights and content

Background: Medicare’s reimbursement system was changed in January 2004 to encourage more frequent visits between dialysis patients and nephrologists. We sought to determine the impact of this policy change on patient-nephrologist visits, quality of care, and health-related quality of life. Methods: We examined visits and outcomes for 2,043 patients at 12 hemodialysis facilities in northeast Ohio for 12 months before and 7 months after the reimbursement change. For comparison of outcomes, we used linear, logistic, or negative binomial regression models (for continuous, binary, and rate outcomes, respectively) to assess the significance of changes across the 2 periods. Results: For patients seen before and after the reimbursement change for at least 6 months, the number of visits per patient-month increased from 1.52 before to 3.14 after (P < 0.001). The percentage of patients with no nephrologist visits per patient-month decreased from 16.6% before to 4.6% after (P < 0.001). However, there were no clinically important changes in Kt/V, albumin level, hemoglobin level, phosphorus level, calcium level, hemodialysis catheter use, ultrafiltration volume, shortened or skipped treatments, hospital admissions, hospitalization days, or health-related quality of life, including patient satisfaction. Conclusion: Despite a marked increase in visits between patients and nephrologists, there was no clinically important impact on parameters related to quality of care or health-related quality of life. Additional work is needed to determine effective payment strategies to improve dialysis patient outcomes.

Section snippets

Subjects and Facilities

We performed a retrospective cohort study of dialysis-related outcomes before and after the January 1, 2004, change in Medicare reimbursement. We included patients who received in-center hemodialysis from January 1, 2003, to July 31, 2004, at 12 free-standing not-for-profit facilities that are part of a single chain in northeast Ohio. Patients receiving peritoneal dialysis or home hemodialysis were not included in this study. Patients with a previous renal transplant who otherwise met inclusion

Subject Characteristics

Of 2,623 patients receiving hemodialysis from January 2003 to July 2004, a total of 2,043 patients (78%) were treated for at least 90 days. Of these, 1,600 patients (61%) were treated before and after the Medicare reimbursement change for a total of at least 6 months during the study. Subject characteristics for these 1,600 subjects are listed in Table 1.

Patient-Nephrologist Visits

Of 59,841 face-to-face nephrologist or physician extender visits, 52,626 (88%) were nephrologist hemodialysis rounding visits, 5,944 (10%)

Discussion

In our study, the CMS reimbursement change was associated with a significant and immediate increase in number of patient-nephrologist visits. As shown in Fig 1, mean number of visits was highly stable after the change was instituted. However, in 7 months of follow-up after the change, no clinically important improvement was observed across a wide range of outcomes. These outcomes include both subjective and objective measures. All these outcomes have well-documented importance. Although the

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    Originally published online as doi:10.1053/j.ajkd.2005.06.012 on August 22, 2005.

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