Renal Disease Prospective Payment System Research Articles

Effect of End-Stage Renal Disease Prospective Payment System on Utilization of Peritoneal Dialysis in Patients with Kidney Allograft Failure

Introduction: The Center for Medicare and Medicaid Services introduced an End-Stage Renal Disease Prospective Payment System (PPS) in 2011 to increase the utilization of home dialysis modalities, including peritoneal dialysis (PD). Several studies have shown a significant increase in PD utilization after PPS implementation. However, its impact on patients with kidney allograft failure remains unknown. Methods: We conducted an interrupted time series analysis using data from the US Renal Data System (USRDS) that include all adult kidney transplant recipients with allograft failure who started dialysis between 2005 and 2019. We compared the PD utilization in the pre-PPS period (2005–2010) to the fully implemented post-PPS period (2014–2019) for early (within 90 days) and late (91–365 days) PD experience. Results: A total of 27,507 adult recipients with allograft failure started dialysis during the study period. There was no difference in early PD utilization between the pre-PPS and the post-PPS period in either immediate change (0.3% increase; 95% CI: −1.95%, 2.54%; p = 0.79) or rate of change over time (0.28% increase per year; 95% CI: −0.16%, 0.72%; p = 0.18). Subgroup analyses revealed a trend toward higher PD utilization post-PPS in for-profit and large-volume dialysis units. There was a significant increase in PD utilization in the post-PPS period in units with low PD experience in the pre-PPS period. Similar findings were seen for the late PD experience. Conclusion: PPS did not significantly increase the overall utilization of PD in patients initiating dialysis after allograft failure.

COVID-19−Associated Decline in the Size of the End-Stage Kidney Disease Population in the United States

COVID-19−Associated Decline in the Size of the End-Stage Kidney Disease Population in the United States

Dialysis Center Productivity Accelerated after 2011 Payment Reform without Compromising Quality of Care

In January 2011, the Centers for Medicare & Medicaid Services (CMS) introduced the End-Stage Renal Disease Prospective Payment System (ESRD PPS) with the goal of creating strong economic incentives for Medicare dialysis providers to improve efficiency in the delivery of dialysis treatments, but without compromising quality of care. To date, no formal evaluations have been published of the impacts of the new payment reforms on dialysis center efficiency in the quantity and quality of care delivered in the pre vs. post PPS era. Our objective was to examine whether the goal of improved efficiency in the delivery of dialysis was achieved without compromise to quality of care in the four years following implementation of the End Stage Renal Disease Prospective Payment System (ESRD PPS) in 2011.

Changes in hemodialysis catheter management after introduction of the end-stage renal disease prospective payment system

BackgroundWe investigated whether implementation of the end-stage renal disease prospective payment system (ESRD PPS) was associated with changes in thrombolytic therapy use and other aspects of catheter management in hemodialysis (HD) patients.MethodsUsing quarterly, period prevalent cohorts of patients undergoing maintenance HD with a catheter in the US Renal Data System (2008–2015), we studied rates of claims for within- and outside-HD-unit thrombolytic use, and thrombus/fibrin sheath removal, and rates of delayed HD treatment after ESRD PPS implementation, January 1, 2011. Associations between PPS implementation and change in trend of rates of each outcome were assessed using covariate-adjusted Poisson regression, using a piecewise linear function for quarter-time (with breakpoint at PPS implementation).ResultsAmong an average of 69,428 quarterly catheter users, rates of claims for within-HD-unit thrombolytic use declined from 236.6 (Q1–2008) to 81.4 (Q4–2012) per 100 person-years (P < 0.0001, PPS association with change in trend); rates of claims for thrombus/fibrin sheath removal procedures increased from 3.9 (Q1–2008) to 8.8 (Q3–2015) per 100 person-years (P = 0.0001, PPS association with change in trend). Rates of delayed HD treatment increased from 1.6 (Q2–2008) to 2.3 (Q3–2015) per patient-quarter, although PPS implementation was associated with a decrease in this rising trend (1.6% increase per quarter pre-PPS, 1.2% post-PPS; P < 0.0001, change in trend).ConclusionsAfter PPS implementation, thrombolytic use decreased and thrombus/fibrin sheath removal increased. The increasing trend in delayed HD treatment appeared to slow after PPS implementation, but delayed sessions continued to increase year over year for unclear reasons.

Impact of the End Stage Renal Disease Prospective Payment System on the Use of Peritoneal Dialysis

IntroductionThe End Stage Renal Disease (ESRD) Prospective Payment System (PPS), implemented by the Centers for Medicare and Medicaid Services in January 2011, encouraged use of peritoneal dialysis (PD) through various financial incentives. Our goal was to determine whether PPS effectively increased PD use in incident dialysis patients.MethodsOur study used the United States Renal Data System (USRDS) to identify 430,927 adult patients who initiated dialysis between 2009 and 2012. The interrupted time series method was used to evaluate the association Centers for Medicare and Medicaid Services of PPS with PD use at dialysis initiation. We further stratified by patient demographics, predialysis care, and facility chain and profit status.ResultsInterrupted time series analysis indicated PPS was associated with increased PD use in the 2-year period after PPS (change in slope = 0.04, P < 0.0001), although there was no immediate change in the level of PD use at the beginning of PPS (P = 0.512). Stratified analyses indicated PPS led to increased PD use across all age, race, and sex groups (P < 0.05) although marginally among females (P = 0.09). Notably, small dialysis organizations and nonprofit organizations appeared to increase use of PD faster compared to large dialysis organizations and for-profit units, respectively.DiscussionImplementation of the Centers for Medicare and Medicaid Services ESRD payment reform was associated with an increased use of PD in the 2 years after PPS. Our findings highlight the role of financial incentives in changing practice patterns to increase use of a dialysis modality considered to be both more cost-effective and empowering to ESRD patients. However, even after PPS, rates of PD use remain low among the dialysis population in the USA.

Hemodialysis Facility Variation in Hospitalization and Transfusions Using Medicare Claims: The DOPPS Practice Monitor for US Dialysis Care

Hemodialysis Facility Variation in Hospitalization and Transfusions Using Medicare Claims: The DOPPS Practice Monitor for US Dialysis Care

Managing oral phosphate binder medication expenditures within the Medicare bundled end-stage renal disease prospective payment system: economic implications for large U.S. dialysis organizations.

From January 2016, payment for oral-only renal medications (including phosphate binders and cinacalcet) was expected to be included in the new Medicare bundled end-stage renal disease (ESRD) prospective payment system (PPS). The implementation of the ESRD PPS has generated concern within the nephrology community because of the potential for inadequate funding and the impact on patient quality of care. To estimate the potential economic impact of the new Medicare bundled ESRD PPS reimbursement from the perspective of a large dialysis organization in the United States. We developed an interactive budget impact model to evaluate the potential economic implications of Medicare payment changes to large dialysis organizations treating patients with ESRD who are receiving phosphate binders. In this analysis, we focused on the budget impact of the intended 2016 integration of oral renal drugs, specifically oral phosphate binders, into the PPS. We also utilized the model to explore the budgetary impact of a variety of potential shifts in phosphate binder market shares under the bundled PPS from 2013 to 2016. The base model predicts that phosphate binder costs will increase to $34.48 per dialysis session in 2016, with estimated U.S. total costs for phosphate binders of over $682 million. Based on these estimates, a projected Medicare PPS $33.44 reimbursement rate for coverage of all oral-only renal medications (i.e., phosphate binders and cinacalcet) would be insufficient to cover these costs. A potential renal drugs and services budget shortfall for large dialysis organizations of almost $346 million was projected. Our findings suggest that large dialysis organizations will be challenged to manage phosphate binder expenditures within the planned Medicare bundled rate structure. As a result, large dialysis organizations may have to make treatment choices in light of potential inadequate funding, which could have important implications for the quality of care for patients with ESRD.

Trends in US Vascular Access Use, Patient Preferences, and Related Practices: An Update From the US DOPPS Practice Monitor With International Comparisons

Since the bundled end-stage renal disease prospective payment system began in 2011 in the United States, some hemodialysis practices have changed substantially, raising the question of whether vascular access practice also has changed. We describe monthly US vascular access use from August 2010 to August 2013 with international comparisons, and other aspects of US vascular access practice. Prospective observational cohort study of vascular access. Maintenance hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS) Practice Monitor (DPM) in the United States (N=3,442; US patients) and 19 other nations (N=8,478). Country, patient demographics, time period. Vascular access use, pre-end-stage renal disease access timing of first nephrologist care and arteriovenous access placement, patient self-reported vascular access preferences (United States only), treatment practices as stated by medical directors. In the United States from August 2010 to August 2013, arteriovenous fistula (AVF) use increased from 63% to 68%, while catheter use declined from 19% to 15%. Although AVF use did not differ greatly across age groups, arteriovenous graft use was 2-fold higher among black (26%) versus nonblack US patients (13%) in 2013. Across 20 countries in 2013, AVF use ranged from 49% to 92%, whereas catheter use ranged from 1% to 45%. Patient-reported vascular access preferences differed by sex and race, with 16% to 20% of patients feeling uninformed regarding benefits/risks of different vascular access types. Among new (incident) US hemodialysis patients, AVF use remains low, with ∼70% initiating hemodialysis therapy with a catheter (60% starting with catheter when having≥4 months of predialysis nephrology care). In the United States, longer typical times to first AVF cannulation were reported. Noncompletion of surveys may affect the generalizability of findings to the wider hemodialysis population. AVF use has increased, with catheter use decreasing among prevalent US hemodialysis patients since the introduction of the prospective payment system. However, AVF use at dialysis therapy initiation remains low, suggesting that reforms affecting predialysis care may be necessary to incentivize improvements in fistula rates at dialysis therapy initiation as achieved for prevalent hemodialysis patients.

Hemoglobin Stability and Patient Compliance With Darbepoetin Alfa in Peritoneal Dialysis Patients After the Implementation of the Prospective Payment System

PurposeSince the Centers for Medicare & Medicaid Services implemented the End-Stage Renal Disease Prospective Payment System, dialysis providers have increasingly focused on balancing resource utilization and quality outcomes for the treatment of anemia in patients undergoing peritoneal dialysis. Limited data exist regarding anemia management outcomes for these patients in US-based dialysis centers after the implementation of the new payment system. MethodsThis was a retrospective, observational, cohort study of stable PD patients with end-stage renal disease who received darbepoetin alfa for anemia management over a 15-month period (April 1, 2011–June 29, 2012). The medication was administered by staff in the home-training unit instead of being self-administered at home. The primary end point was mean quarterly hemoglobin (Hb) levels. Variability in Hb levels was assessed over the 5 quarters by using repeated measures ANOVA to test for differences in the observed mean SDs. FindingsIn the 139 adult patients on stable peritoneal dialysis and meeting the eligibility criteria, mean (SD) Hb level by quarter was 10.8 (1.2) g/dL in quarters 2 and 3 of 2011, 10.5 (1.1) g/dL in quarter 4 of 2011, and 10.4 (1.1) g/dL in quarters 1 and 2 of 2012. Hb levels were stable (mean SDs, 0.58–0.72) over the 5 quarters of the study. Patient compliance with attendance for all scheduled home training unit visits was 84%. ImplicationsPD patients who underwent darbepoetin alfa administration and twice-monthly laboratory testing in the home-training unit had stable Hb levels. Despite more frequent center visits compared with a home-administered approach, patient compliance was high.

Development and Evaluation of the CAHPS (Consumer Assessment of Healthcare Providers and Systems) Survey for In-Center Hemodialysis Patients

The US Centers for Medicare & Medicaid Services assess patient experiences of care as part of the end-stage renal disease prospective payment system and Quality Incentive Program. This article describes the development and evaluation of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) In-Center Hemodialysis Survey. We conducted formative research to generate survey questions and performed statistical analyses to evaluate the survey's measurement properties. Formative research included focus groups, cognitive interviews, and field testing the survey with dialysis patients. We assessed internal consistency reliability (Cronbach alpha) and center-level reliability for 3 multi-item scales. We evaluated construct validity using correlations of the scales with global ratings of the kidney doctor, staff, and dialysis center. Response rate was 46% (1,454 completed surveys). Analyses support 3 multi-item scales: Nephrologists' Communication and Caring (7 items, alpha=0.89), Quality of Dialysis Center Care and Operations (22 items, alpha=0.93), and Providing Information to Patients (11 items, alpha=0.75). The communication scale was correlated the most strongly with the global rating of the "kidney doctor" (r=0.78). The Dialysis Center Care and Operations scale was correlated most strongly with global ratings of staff (r=0.75) and the center (r=0.69). Providing Information to Patients was correlated most strongly with the global rating of the staff (r=0.41). A relatively small number of patients completed the survey in Spanish. This study provides support for the reliability and validity of the CAHPS In-Center Hemodialysis Survey for assessing patient experiences of care at dialysis facilities. The survey can be used to compare care provided at different facilities.

The DOPPS Practice Monitor for US Dialysis Care: Potential Impact of Recent Guidelines and Regulatory Changes on Management of Mineral and Bone Disorder Among US Hemodialysis Patients

The DOPPS Practice Monitor for US Dialysis Care: Potential Impact of Recent Guidelines and Regulatory Changes on Management of Mineral and Bone Disorder Among US Hemodialysis Patients

The DOPPS Practice Monitor for US Dialysis Care: Update on Trends in Anemia Management 2 Years Into the Bundle

From Arbor Research Collaborative for Health, Ann Arbor, MI. Originally published online October 21, 2013. Concepts presented in this article are based on data available at the DPM website and may have appeared in resources and media releases distributed by DPM. Address correspondence to Douglas S. Fuller, MS, Arbor Research Collaborative for Health, 340 E Huron St, Ste 300, Ann Arbor, MI 48104. E-mail: doug.fuller@arborresearch.org 2013 by the National Kidney Foundation, Inc. 0272-6386/$36.00 http://dx.doi.org/10.1053/j.ajkd.2013.09.006 The Dialysis Outcomes and Practice Patterns Study (DOPPS) Practice Monitor (DPM) was developed to detect and report on trends in dialysis care before, during, and after implementation of the end-stage renal disease prospective payment system (PPS), which was initiated by the US Centers for Medicare & Medicaid Services (CMS) in January 2011. The DPM is based on a national sample of US hemodialysis facilities, with sampling weighting techniques used to calculate nationally representative statistics. The DPM is updated every 4 months at www.dopps.org/DPM, with data available after a lag period of just 2-4 months. The rationale and methods of the DPM have been described previously and statistics based on the DPM sample have been shown to closely correspond to other published national data. As a continuation of previous publications in AJKD, here we highlight trends in anemia from August 2010 through December 2012. As discussed in previous DPM updates, several changes provided direct impetus for US dialysis centers to change anemia management during this period: the addition of previously separate billable services including erythropoiesis-stimulating agents (ESAs) and intravenous (IV) iron to the composite bundled dialysis payment rate, a revised ESA label approved by the US Food and Drug Administration (FDA) that removed a specific target for hemoglobin (Hb) level (June 2011), and soon after, the discontinuation by the CMS Quality Incentive Program of the payment penalty for Hb levels , 10 g/dL. DPM data reported here reflect an average of 3,504 (range, 2,131-4,191) hemodialysis patients in 96 (range, 74-110) facilities per month over a 29-month period. Data are aggregated across facilities and dialysis organizations; thus, aggregated trends may not reflect trends in individual facilities or dialysis organizations.

Understanding Washington: A Nephrologist's Perspective From Inside the Beltway

The major principles that drive U.S. federal health policy-making are: (1) fixed or reduced costs, (2) ensured outcomes (or no evidence of undertreatment), (3) streamlined administration, and (4) political viability. A corollary is that providers are uniquely sensitive to financial incentives. Understanding these principles is vital to understanding federal health policy. Critically, these principles are nonpartisan and have been supported and used by all administrations since President Reagan. This article examines the end-stage renal disease (ESRD) prospective payment system, colloquially called "The Bundle," in the context of these major principles. Successful health policy, successful legislation, and successful regulation building all require executive leadership, mutual trust, and compromise. This is demonstrated by the events surrounding the passage of the Medicare inpatient prospective payment system, which governs hospital reimbursement for Medicare beneficiaries, including those not covered in the ESRD program. Given that the ESRD benefit consumes 6.3% of the Medicare budget for approximately 2% of Medicare beneficiaries, if nephrology is to experience future success, we must change how both policymakers and the wider field of medicine perceive our specialty. Understanding the major principles behind health care policy may facilitate this goal.

What can we learn from the U.S. expanded end-stage renal disease bundle?

Episode-based payment, commonly referred to as bundled payment, has emerged as a key component of U.S. health care payment reform. Bundled payments are appealing as they share the financial risk of treating patients between payers and providers, encouraging the delivery of cost-effective care. A closely watched example is the U.S. End Stage Renal Disease (ESRD) Prospective Payment System, known as the ‘expanded ESRD bundle.’ In this paper we consider the expanded ESRD bundle 2 years after its implementation. First, we discuss emerging lessons, including how implementation has changed dialysis care with respect to the use of erythropoietin stimulating agents, how implementation has led to an increase in the use of home-based peritoneal dialysis, and how it may have contributed to the market consolidation of dialysis providers. Second, we use the expanded ESRD bundle to illustrate the importance of accounting for stakeholder input and staging policy implementation. Third, we highlight the need to consider system-wide consequences of implementing bundled payment policies. Fourth, we suggest how bundled payments may create research opportunities. Bundled payment policies offer opportunities and challenges. Their success will be determined not only by impacts on cost containment, but also to the extent they encourage high quality care.

The DOPPS Practice Monitor for US Dialysis Care: Trends Through December 2011

The Dialysis Outcomes and Practice Patterns Study (DOPPS) Practice Monitor1 (DPM) was developed to inform the dialysis community of contemporary trends in dialysis treatment practices and patient outcomes, with the launch in 2010 timed to follow care before and after implementation of the end-stage renal disease prospective payment system (PPS) by the US Centers for Medicare & Medicaid Services (CMS) in January 2011. Publicly available updates are provided every 4 months at the DPM website (www.dopps.org/DPM).

Financial Implications of Choice of Dialysis Type of the Revised Medicare Payment System: An Economic Analysis

In 2011, the Medicare Improvements for Patients and Providers Act replaced the case-mix-adjusted composite payment system for Medicare outpatient dialysis facilities with a bundled end-stage renal disease prospective payment system (PPS). We assessed the economic implications for modality choice of the revised Medicare payment system. Microeconomic analyses. Patients eligible for dialysis in the United States. The perspective of this analysis is that of a financial administrator of a representative dialysis center in the United States. Data were obtained from the Medicare Payment Advisory Commission, the US Renal Data System, the DOPPS (Dialysis Outcomes and Practice Patterns Study) Practice Monitor, the US Bureau of Labor Statistics, and Medicare fee schedules. Recently implemented end-stage renal disease PPS versus the prior case-mix composite payment system. Medicare payment per month, center fixed and variable costs per month, net difference in revenue and variable costs (direct contribution), and net difference in revenue and total costs (operating margin). The direct contribution and operating margin for in-center hemodialysis and peritoneal dialysis are expected to be positive under the new bundled PPS. For Medicare fiscal intermediaries/administrators, paid treatments for home hemodialysis vary from 3.2 to more than 4.8 per week. The direct contribution and operating margin are expected to be negative for home hemodialysis if the number of paid treatments is similar between in-center and home hemodialysis; they are almost identical when the number of paid treatments increases for home hemodialysis by approximately 1 per week. Experience across centers and intermediaries/administrators may vary. Sensitivity analyses were conducted to assess the robustness of findings and determine which variables most influenced results. The new bundled PPS created a financial incentive for increased use of peritoneal dialysis. Use of home hemodialysis may be influenced by number of paid treatments per week.

The effect of bundling on peritoneal dialysis: Challenges and opportunities to improve outcomes and change the “default”

The effect of bundling on peritoneal dialysis: Challenges and opportunities to improve outcomes and change the “default”

The Dialysis Outcomes and Practice Patterns Study (DOPPS) Practice Monitor: Rationale and Methods for an Initiative to Monitor the New US Bundled Dialysis Payment System

A new initiative of the US Dialysis Outcomes and Practice Patterns Study (DOPPS), the DOPPS Practice Monitor (DPM), provides up-to-date data and analyses to monitor trends in dialysis practice during implementation of the new Centers for Medicare & Medicaid Services (CMS) end-stage renal disease Prospective Payment System (PPS; 2011-2014). We review DPM rationale, design, sampling approach, analytic methods, and facility sample characteristics. Using stratified random sampling, the sample of ~145 US facilities provides results representative nationally and by facility type (dialysis organization size, rural/urban, free standing/hospital based), achieving coverage similar to the CMS sample frame at average values and tails of the distributions for key measures and patient characteristics. A publicly available web report (www.dopps.org/DPM) provides detailed trends, including demographic, comorbidity, and dialysis data; medications; vascular access; and quality of life. Findings are updated every 4 months with a lag of only 3-4 months. Baseline data are from mid-2010, before the new PPS. In sum, the DPM provides timely representative data to monitor effects of the expanded PPS on dialysis practice. Findings can serve as an early warning system for possible adverse effects on clinical care and as a basis for community outreach, editorial comment, and informed advocacy.

69 Surveying the Impact of the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) on Hospital Based Dialysis Centers (HBDCS)

SURVEYING THE IMPACT OF THE END-STAGE RENAL DISEASE (ESRD) PROSPECTIVE PAYMENT SYSTEM (PPS) ON HOSPITAL BASED DIALYSIS CENTERS (HBDCS) George Coritsidis, Anjali Acharya, Ross Miller, Kelly Ko, Akhtar Ashfaq, Irene Agodoa; NYC Health and Hospitals Corporation (HHC), New York, NY, USA; Cerner Life Sciences, Beverly Hills, CA, USA; Amgen Inc, Thousand Oaks, CA, USA; The ESRD PPS will begin on January 1, 2011 and has the potential to impact HBDC financial stability, quality and patient access to care. This survey was designed to collect data related to HBDC’s perceptions of the PPS. Between Oct 2009 and Feb 2010, an online baseline questionnaire was sent to all HBDCs in the US (N=910) using the 2006 CMS provider file. Of the 910 HBDCs included in the CMS provider file, 669 were successfully contacted and 128 (19%) of facilities completed the survey. Respondents from dialysis centers affiliated with smaller hospitals (<200 beds) were more concerned that the new PPS may create financial risk (85.0% vs. 75.0%) compared to those affiliated with larger hospitals (≥200 beds). The figure provides an overview of HBDC perceptions around the consequences of the PPS.

9: A Simplified Case-Mix Adjuster Model for the Proposed End Stage Renal Disease (ESRD) Prospective Payment System (PPS)

9: A Simplified Case-Mix Adjuster Model for the Proposed End Stage Renal Disease (ESRD) Prospective Payment System (PPS)