Coordination of Care in Disease Management: Opportunities and Financial Issues

Abstract

Patients with end-stage renal disease (ESRD) and pre-ESRD require higher utilization of health care resources. Current reimbursement modalities contribute to the fragmentation of care, and inadequate financial information obscures the fiscal impact disease management's coordination of care can have for this population. Ignoring the extreme costs of the first 3 months of hemodialysis underestimates costs by as much as 16%. Potential areas of coordination and the financial benefits are discussed. In each venue of the care settings of a patient with chronic renal failure (CRF) they may receive excellent service. Too often there is not optimal coordination of care between these venues, and in fact the fragmentation of care can cause unnecessary wear and tear on the patient, and increases the overall expense to a health care system. Understanding sources of fragmentation, reimbursement effects, and potential corrections will enhance the patient's voyage through the system. This article provides some examples of the discoordination that presently exists and financial implications especially during the transition onto dialysis. In patients with end-stage renal disease (ESRD), each arena of care has criteria established to quantitate quality. None of the settings, whether it is the dialysis unit, the hospital, the skilled nursing facility, or the physician's office, exists in the absence of regulations. These may be state or federal, National Council on Quality Assurance (NCQA), Health Plan Employer Data and Information Set (HEDIS), water standards, Occupational Safety and Health Administration (OSHA), fire codes, physician peer review, Medicare billing, Health Care Finance Administration (HCFA), the ESRD networks, credentialing, health maintenance organization (HMO) insurance requirements, pharmacy benefits and formularies, safe harbors, "antikickback," or National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI) guidelines. For all the providers of care, the other critical component is the ability to have adequate income to stay in business, and make a profit. Each becomes very astute at working within the confines of the regulatory restrictions to provide good care. However, the continuity of care cannot be the overwhelming issue for many of the providers. The only person that is involved in every arena is the patient. The only provider that currently crosses over most arenas is the nephrologist. But the other element that exists in each arena is a payer.