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November 27, 2013

CMS Issued a Final Ruling on 2014 Dialysis Payment Rates

As many of you may know, on Nov. 22, the Centers for Medicare & Medicaid Services (CMS) issued its final rule on 2014 payment rates for dialysis facilities paid under the End Stage Renal Disease Prospective Payment System (ESRD PPS) as well as updates to the Quality Incentive Program (QIP). CMS first announced a proposed cut of 12 percent(1) from Medicare’s ESRD program in July, potentially threatening access to dialysis care for thousands of patients with kidney disease across the country.

Thanks to the support from our physician partners, patients, teammates and other members of the kidney care community over the last few months, we were able to generate more than 124,000 contacts to Congress asking them to help stop the cuts. Our combined efforts were a success, resulting in flat rates over the next two years and continued access to dialysis care for our patients. But we still have some work to do to help mitigate future cuts. Read more…

August 1, 2013

Medicare and Dialysis: A History Lesson Unheeded

“July and August will be critical months to take our message to Washington: no more cuts for dialysis patients and their providers.”


The recent proposal from the Centers for Medicare & Medicaid Services (CMS) to cut reimbursement for dialysis treatments by 9.4 percent has made me think hard about where dialysis has been, where it is now and where it might be headed. When I began my internship and residency at Michael Reese Hospital in Chicago (now gone, unfortunately), the Medicare entitlement for dialysis had not yet been enacted. Michael Reese had a long connection with pioneers in dialysis dating back to the 1920s. During my internship I rotated on the nephrology service. We had converted a hospital room to a dialysis ward and built Kiil dialyzers each time we wanted to do hemodialysis. We created Scribner shunts for blood access, and each treatment was an exciting challenge to get through without hypotension, clotting or other misadventures. We also had more than 40 patients on intermittent peritoneal dialysis (IPD). They would be admitted to the hospital each week, have a peritoneal catheter inserted and receive 48 hours of IPD. As the intern on the service, I admitted each patient, drew blood and then ran a set of electrolytes in a dedicated lab on the ward. I prescribed the peritoneal dialysis regimen for the 48 hours based on the physical examination and laboratory values. The Medicare entitlement for dialysis was enacted in the first year of my residency, 1972, and implemented in 1973. It changed everything.

Read more…

June 14, 2013

Breaking the Chains of Clinical Practice Guidelines: Could SCAMPs Be the Answer?

I have written extensively about the challenges in driving better outcomes in our patients with advanced CKD and ESRD. Not the least of these is the continued reliance of clinicians, payers and regulators on clinical practice guidelines (CPGs) to determine what domains are worthy of focus for public reporting and for payment to dialysis facilities. Unfortunately, however, the CPGs in nephrology are small in number and, despite excellent performance across the ESRD population on overall, we have not moved the needle on the really important primary outcomes that will ultimately result in better lives for our patients: lower mortality, fewer hospitalizations and an improved experience of care.

A nephrologist with a happy patient and caregiver.A recent article in Health Affairs described a different approach to achieving the goals for which we all strive—the use of standardized clinical assessment and management plans (SCAMPs), “a clinician-designed approach to promoting care standardization that accommodates patients’ individual differences, respects providers’ clinical acumen, and keeps pace with the rapid growth of medical knowledge.”(1) This approach was developed and has been applied largely by pediatricians as an outgrowth of their frustration with CPGs. Nearly 50 SCAMPs have been developed, and more than 12,000 patients currently are enrolled in SCAMP programs. Read more…

May 14, 2013

Orals in the Bundle: Meds Matter

Patients with ESRD are the most medication-burdened of all the chronically ill. They take an average of 8 to 10 different medications, consuming more than 20 pills per day. It is not surprising, therefore, that the ability of nephrologists, dialysis facilities and patients to manage these medications is a challenge. Patients often do not know what medications they are on, and the monthly “pill check”—usually a shoebox filled with medication bottles—is notoriously inaccurate (1). More importantly, it has been estimated that up to a third of hospitalizations among the frail elderly (which includes a significant number of ESRD patients), and nearly half of re-hospitalizations in this population, are related to medication errors or adverse reactions. Finally, because of the large pill burden, the high costs of some medications and the significant occurrence of adverse events, adherence to prescribed medications is suboptimal (2).

Medications in a medicine cabinet.Integrated pharmacy services can help resolve many of these issues for ESRD patients, as recently demonstrated by Weinhandl et al (3). This study compared nearly 9,000 patients enrolled in the DaVita Rx full-service pharmacy program to more than 40,000 control patients not in the program. Read more…

March 27, 2013

Where Have All the Nephrologists Gone? Long Time Passing!

We are seeing a continual increase in the number of US patients with CKD and ESRD. The epidemic of obesity, and resultant diabetes and hypertension, has not abated and will continue to swell the ranks of patients needing care from nephrologists. Add to this the incredible improvement in the survival rate of ESRD patients over the last decade and the extended availability of medical care to the uninsured thanks to the Affordable Care Act, and we are indeed on the brink of a tidal wave of kidney patients. These facts should be a wake-up call to health policy-makers, especially in light of the shocking statistics from the most recent Medical Specialties Matching Program (MSMP)(1). For appointment year 2013, MSMP indicates that nearly a quarter of nephrology fellowship programs had unfilled positions, the worst of all medical subspecialties. Only 25 percent of positions were filled by US graduates overall and only 21 percent of clinical nephrology positions are filled by US graduates—the lowest of any medical subspecialty. Read more…

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