In previous blogs I have talked about the highly fragmented care our patients receive, and how this leads to poor outcomes. This comes as no surprise to any busy nephrologist who struggles to juggle the multiple renal and comorbidity-related issues for these complex and fragile patients.  Most advanced CKD/ESRD patients are seeing 3- 4 additional physicians including a primary care doctor and multiple specialists. The ability of the nephrologist to know what is happening, in real time, is nearly impossible in the current care paradigm.

Within the dialysis facility there is a reasonable level of sophistication in the electronic capture, analysis and reporting of relevant clinical data to the nephrologist. Dialysis providers have developed systems that capture clinical and billing data and such information is increasingly becoming available to nephrologists not only in the dialysis facility but through security-protected web portals.

This is all fine, and some systems are more robust than others, but the real problem remains that only a fraction of the healthcare received by these patients takes place in a dialysis center. There is a crying need to have a truly integrated electronic health record (EHR) so that the care delivered by all relevant physicians, at all sites of care, including hospitals, will be available to the nephrologist in real time.

Now, adding the fact that Nephrologists providing dialysis care may have up to 85% of their patients on Medicare, the failure to implement “meaningful use” of a certified EHR in their practices sets them up to lose revenue due to reimbursement penalties imposed by the government.

Because of the complexity of nephrology practices and the diversity of their daily workflow, a nephrologist would be hard pressed to take a cookie cutter EHR “off the shelf” and expect that it will not only help them avoid reimbursement penalties but actually optimize the care of their patients.

There is good news here – some dialysis providers have decided to throw their hats into the ring and develop nephrology-focused EHRs. The key to nephrology-focused EHRs is that they have been created with the specific needs of nephrologists in mind. At least one of the nephrology-focused EHRs on the market integrates data from dialysis facilities into the nephrologist’s office EHR system to manage patients with ESRD. Such systems are also capable of capturing data in the office on CKD patients in a way that covers the continuum of an individual patient’s renal disease progression. If ACOs become a reality, the EHR that has the flexibility to truly integrate all relevant data as it becomes available, will be better positioned to close the loop – optimizing the delivery of patient care, as required by CMS for any approved ACO.

Bringing an EHR into the nephrology office is to some a daunting task, requiring large capital expenditures and technical expertise. Dialysis providers developing such systems and commercial vendors of generic EHRs being marketed to nephrology groups need to have the flexibility to work collaboratively with nephrology practices to address these issues to help ensure that the practice realizes the full potential of their chosen EHR  to improve care for patients and ease the administrative burden. If this can be done, nephrology patients will receive better care, and integration of care will be much more likely to accelerate.

As clearly stated by President Bush and President Obama:

“We need to reduce costs and medical errors with better information technology.”
President George W. Bush;  State of the Union Address;  January 23, 2007

“Our recovery plan will invest in electronic health records and new technology that will reduce errors, bring down costs, ensure privacy, and save lives.”
President Barack Obama; Address to Joint Session of Congress; February 24th, 2009

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

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While nephrologists are very familiar with the uniqueness of the Medicare entitlement for ESRD patients, the critical importance, structure, and challenges to the Medicaid program that directly impact ESRD patients are less well known.  Medicaid came into being in 1965 part of the same legislation that created Medicare.  It was designed to be complimentary to Medicare- to provide a safety net for the support of health care delivery to individuals who could not afford to pay for care.  Medicaid is different from Medicare however, since it is financed through a Federal/State sharing of cost program.  There are no limits on what a given state can spend on its Medicaid program, and the Federal spending match is determined by formula varying from 50% of state costs (in 18 states) up to 74.3% (in Mississippi).  The matching formula is based on state per capita personal income compared to the national average.

The current economic recession has been a disaster for Medicaid programs and there is no light at the end of that tunnel.  Falling state revenues and an incredible increase in the enrollment in Medicaid programs have driven states to draconian measures to stop the bleeding.  By the end of 2009 nearly 49 million Americans, one in six, were covered by Medicaid.  Although MIPPA increased the Federal share of costs temporarily, that is coming to an end, and after July 1^st of this year the Federal contribution will return to pre-2009 levels.

How are states responding to this crisis?  Not rocket science- cut reimbursement to providers, renew the push to move Medicaid patients into managed care, create more restrictive medication formularies, and eliminate some high cost procedures from the list of covered services.  The result will be less access to care, increased use of emergency services and withholding of medically needed services- all leading to unacceptable health outcomes for some of our most vulnerable.

For patients with ESRD significant Medicaid cuts proposed in North and South Carolina, Louisiana, Texas, Minnesota, California, Illinois and many other states could be devastating.  But in the face of these challenges, nephrologists and the renal community have an opportunity to step forward and help states understand that creative approaches to improving quality for Medicaid patients with ESRD can also drive lower costs.  Removing barriers to permanent access placement and avoiding catheter placement; increasing the emphasis on starting home therapy as an initial dialytic modality; initiating care coordination/care management in Stage 4 CKD are just three of the ways states could save money by investing in better care.

As a renal community we need to get involved in our individual states, educate them about the ways better quality for ESRD patients can control costs in their Medicaid programs and then we need to partner within our states to make this ideas become reality.  I had the privilege of spending 1994-95 working with Senator Paul Wellstone from Minnesota.  He stated:

“ …how can we live in the richest, most privileged country in the world, at the peak of its economic performance, and still hear [from politicians] that we cannot afford to provide a good education for every child, that we cannot afford to provide health security for all our citizens?”
— Paul Wellstone (The Conscience of a Liberal: Reclaiming the Compassionate Agenda)

Like Senator Wellstone I know we can do better.

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

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