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Hemodialysis Hospitalizations and Readmissions: The Effects of Payment Reform
Kevin F Erickson1, Wolfgang C Winkelmayer2, Glenn M Chertow3
1Section of Nephrology, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX; Center for Innovations in Quality, Effectiveness and Safety, Baylor College of Medicine, Houston, TX.
Insights
A 2004 Medicare policy incentivizing more frequent hemodialysis visits did not reduce all-cause hospitalizations. While fluid overload hospitalizations slightly decreased, the policy incurred significant costs, highlighting potential economic inefficiencies in pay-for-performance initiatives.
Area of Science:
- Health Services Research
- Health Economics
- Nephrology
Background:
- In 2004, Medicare shifted hemodialysis reimbursement to a tiered fee-for-service model, encouraging more frequent provider visits.
- This pay-for-performance initiative aimed to improve care processes for hemodialysis patients.
Purpose of the Study:
- To evaluate the impact of the 2004 Medicare reimbursement reform on hospitalizations and rehospitalizations in hemodialysis patients.
- To estimate the economic costs associated with increased provider visits following the reform.
Main Methods:
- Retrospective cohort interrupted time-series study design.
- Analysis of Medicare beneficiaries receiving hemodialysis in the two years before and after the 2004 reimbursement reform.
- Estimation of economic costs using published data.
Main Results:
- No significant change was observed in all-cause hospitalizations or rehospitalizations.
- Slight reductions were noted in hospitalizations and rehospitalizations for fluid overload.
- Estimated annual economic costs for additional visits ranged from $13 to $87 million.
Conclusions:
- The Medicare reimbursement policy may have been costly without a significant impact on overall hospitalizations.
- The policy showed a modest benefit in reducing fluid overload-related hospitalizations but not all-cause events.
- Limited data on provider time prevented precise cost analysis, indicating a need for better tracking in policy evaluation.
Background:
In 2004, the Centers for Medicare & Medicaid Services changed reimbursement for physicians and advanced practitioners caring for patients receiving hemodialysis from a capitated to a tiered fee-for-service system, encouraging increased face-to-face visits. This early version of a pay-for-performance initiative targeted a care process: more frequent provider visits in hemodialysis. Although more frequent provider visits in hemodialysis are associated with fewer hospitalizations and rehospitalizations, it is unknown whether encouraging more frequent visits through reimbursement policy also yielded these benefits.
Study Design:
We used a retrospective cohort interrupted time-series study design to examine whether the 2004 nephrologist reimbursement reform led to reduced hospitalizations and rehospitalizations. We also used published data to estimate a range of annual economic costs associated with more frequent visits.
Setting & Participants:
Medicare beneficiaries in the United States receiving hemodialysis in the 2 years prior to and following reimbursement reform.
Predictor:
The 2 years following nephrologist reimbursement reform.
Outcomes:
Odds of hospitalization and 30-day hospital readmission for all causes and fluid overload; US dollars.
Results:
We found no significant change in all-cause hospitalization or rehospitalization and slight reductions in fluid overload hospitalization and rehospitalization following reimbursement reform; the estimated economic cost associated with additional visits ranged from $13 to $87 million per year, depending on who (physicians or advanced practitioners) spent additional time visiting patients and how much additional effort was involved.
Limitations:
Due to limited information about how much additional time providers spent seeing patients after reimbursement reform, we could only examine a range of potential economic costs associated with the reform.
Conclusions:
A Medicare reimbursement policy designed to encourage more frequent visits during outpatient hemodialysis may have been costly. The policy was associated with fewer hospitalizations and rehospitalizations for fluid overload, but had no effect on all-cause hospitalizations or rehospitalizations.
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