The New York Times recently highlighted a new program being introduced as part of the evaluation of applicants for medical school.  A handful of medical schools are now assessing social skills, having the applicants interview nine “patients” with serious social or ethical problems.  Not only are social skills assessed, but also the ability of the applicants to work together in small teams.  As nephrologists, we know patients with chronic illnesses, including CKD/ESRD, are among the most needy in this regard, requiring physicians who listen and are able to work effectively in teams, whether within their practice, with other doctors, or with the interdisciplinary team in a dialysis facility.

A recent medical crisis with my Mother made me think hard about how physicians, patients and caregivers communicate nowadays in the world of technology-driven medicine and electronic communication.  Although my mother does not have CKD/ESRD, she does have significant chronic illnesses.  She is 85 years old and as mentally sharp and energetic as she was 50 years ago.  Over the years, she has developed diabetes, hypertension and, more recently, slowly progressive liver dysfunction (“cryptogenic cirrhosis”).  The latter has been the most problematic, leading to two hospitalizations over the past 3 years with hepatic encephalopathy.  Both of these hospitalizations were handled quickly and efficiently, poor control of blood sugar and blood pressure had pushed her over the metabolic edge, and she quickly recovered with appropriate attention to these issues.

A month ago, I got a call from my sister telling me Mom was admitted again, confused, agitated and disoriented.  This seemed like another one of her metabolic “episodes”, but the ER physician decided to order a brain MRI, EEG and neurology consult.  He did not pull up her medical records or listen to the history given by my sisters.  The MRI showed a small area of scarring (likely from a fall a few years ago) and the EEG was “abnormal”.  The neurologist could not interview my mom, who was still confused, and told my sisters that mom had status epilepticus based on the EEG and started her on high dose Keppra.  One could predict the result- extreme fatigue, inability to ambulate and growing depression.

When I got this news, I called the neurologist to get the direct information on what had happened.  The neurologist who made the diagnosis was not on hospital duty any longer and her associate was, but was not available.  I asked for an email address and was told, “his policy is not to provide email addresses to patients or families”.  The next day, I got a message that he also had spoken to my sisters and that, despite my being a physician, his policy was only to speak with a single family member.  I was finally able to contact the initial neurologist who was the “seizure specialist” of the group, who described why she made the diagnosis she did.

I asked if it was possible that the abnormal EEG was related to metabolic encephalopathy, since the clinical episode was so similar to previous episodes.  I also asked what the clinical manifestations of status epilepticus were- she could not answer either question but was adamant that the diagnosis was correct.  When I suggested tapering the Keppra to see if the now-corrected metabolic problems were the true precipitating cause, she stated that she would not consider that for at least a year.

I got a second opinion from a local academic institution- the chief of the epilepsy service interviewed my mom, reviewed the tests and immediately started tapering the Keppra.  He stated that the diagnosis was incorrect but an honest mistake, since the neurologist couldn’t interview my mom and did not have direct access to her previous records.  After 3 weeks of slowly tapering off the Keppra, my mom is back to her normal, ambulating, bubbly self.

The point?  Poor communication, over-reliance on high-tech procedures and inability or unwillingness to interact with the family – when the patient was unable to provide clear information – were at the root of the mistake.  Such situations occur daily with patients on dialysis and the increasing reliance of nephrologists on physician extenders further extends the gap between patient and doctor.  I hope that nephrologists will again reexamine the value of spending time with patients,  listening to them and better understanding what they want and need.  The technical aspects of dialysis are generally well performed but to truly deliver holistic care, we must all remember this is done one patient at a time, at the bedside, and it takes time and commitment.

As made famous in Cool Hand Luke:  “What we have here is a failure to communicate”.  That should never be the case in the practice of the art of medicine.

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

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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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My last blog described the terribly fragmented healthcare delivery system that nephrologists, and, more importantly, patients have to navigate just to get reasonable care. We all know that this system, particularly for the frail, elderly and chronically ill is terribly broken. Well over a year ago a new savior was introduced to the healthcare/health policy area—Accountable Care Organizations or ACOs.  This was touted as a new approach for financing care, but making providers accountable for holistic care of a population of patients, holding providers to specific quality targets, and rewarding excellence in quality, also resulted in financial savings. Most providers understood that to achieve higher quality and constrain costs, reorganization of the delivery paradigm would be necessary and collaboration would be the key to success.

Almost immediately hospitals jumped onto the ACO bandwagon—since in any redesign of a massive system like healthcare there would clearly be winners and losers—and hospitals saw the potential improvement in quality and focus on efficiency eroding their revenues and their influence.  They began buying physician practices as a way of mitigating this problem—physician employees would be loyal to the hospital, would accept lower salaries, and all would be well. Some specialties followed this path in lockstep-, more than 70% of cardiologists now work as salaried employees of health systems, primarily hospitals or other integrated care systems.

Nephrologists have always been independent thinkers and have largely resisted making such hasty decisions. While acknowledging that ACOs may provide an opportunity to improve quality and to permit excellent nephrologists to share in the financial savings, they are none too happy about getting in bed with hospitals. Of much more interest to nephrologists is how they might convince the healthcare community and CMS that an ACO structure with the nephrologist as the principal care providers makes the most sense for ESRD patients, and for the overall goals of improving outcomes and controlling costs.

ESRD patients are the prototype of the chronically ill—average age over 60, three to four co-morbid conditions, on eight to 10 different medicines, seeing one to four additional specialists, in the hospital 12 to18 days per year, and despite small numbers (<1% of all Medicare patients), consuming massive amounts of Medicare dollars (7-10%). Recently completed demonstration projects show that the renal community knows how to re-engineer care for this population, drive better care, and lower hospitalization rates and total costs. Delivering holistic care to these vulnerable patients can only be done with the leadership of nephrologists, and the time for this is now. While the preliminary regulations issued by CMS would make an ACO with ESRD patients as the designated members, with nephrologists as principal care providers not possible, the Center of Medicare and Medicaid Innovation (CMMI) is very interested in such an approach. As a renal community we need to fight to make sure that this is an option that is made available to our patients and to us as providers concerned about achieving the best possible outcomes for our patients.

As patient advocates we should be concerned that the complexity of care needed by ESRD patients will overwhelm a general ACO and our patients will either not benefit from the care coordination approach or will be excluded from joining. Neither of these would be acceptable options.  DaVita, Fresenius and the Renal Physicians Association are working hard together to educate CMMI on the value of an ACO focused on ESRD patients to the patients and the overall healthcare system. With continued persuasive dialogue we are hopeful that this view will prevail and that pilots of this approach will be permitted soon. For continued information on this topic and to further express your views please respond to this blog and check out the Accountable Kidney Care Collaborative website and its blog as well.

Senator John Kerry said it well: “Fixing our healthcare system as a whole is our primary challenge, and to make it happen you need to get engaged–to pound the pavement, get your hands dirty, endure real sacrifice, take on antiquated thinking and help lead the public debate.”

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

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I have a close friend, Eliot who is a highly successful academic physician.  I have known him for nearly 35 years, and our lives have crossed in many interesting ways over the years.  He grew up in an affluent suburb in Boston, similar to where I grew up in Chicago, each of us part of large loving families including incredible younger brothers with whom we were very close.  He has done extensive work with NIH and industry funded research in his area of interest, similar to my work in kidney disease.  This story is not really about me or Eliot, but about Eliot’s brother, Steve.

Steve was four years younger than Eliot and as he grew and started high school it became clear that he had an incredible intellectual gift.  Many called him a genius, and he excelled not only in academics, but had a full and rewarding social life.  No one was surprised when he was accepted to Stanford for undergraduate work, and he settled into California smoothly.  He decided to become a doctor, like his older brother and was accepted to Stanford Medical School.  During his senior year at Stanford undergraduate, however, things started to change and by the middle of his freshman year in medical school he was diagnosed with schizophrenia.  He struggled valiantly to continue with many adjustments in medications but by sophomore year he had to drop out and shortly thereafter he was living in an  assisted living facility.  Two years later he had a complete medical evaluation because of severe fatigue and was found to have CKD- a kidney biopsy was consistent with amyloidosis.  Over the next three years he developed ESRD and started in-center hemodialysis.

By this time Steve was approaching 40 years old, and because of a family history of colon cancer his primary care doctor felt a screening colonoscopy should be performed.   The procedure was scheduled on a day between dialysis days, the colon was normal except for a few benign looking polyps which were biopsied, and there were no complications noted.  Steve returned for an uneventful  routine dialysis the following day, went home, and was found the next morning in a massive pool of blood.  He had bled to death from his rectum during the night.

Did Steve have an incompetent PCP or nephrologist?  A lousy dialysis facility?  Bad luck?  NO!  Steve was a tragic example of the highly fragmented care that is delivered to patients with kidney disease that leads to poor outcomes and limits the ability of patients to achieve their full quantity and quality of life despite having a devastating illness.  The fact that a care delivery system could fail so badly, even for highly educated patients, is unacceptable.  ESRD patients are among the most complex medically that have to navigate this system- 3-4 co-morbid conditions, 8-10 different medications, 3-7 physician providers, and on it goes.  Add to this the lack of an electronic health record, and the current disorganized care is understandable- the system is broken.

Of course the reimbursement system magnifies this compartmentalization of care.  Investing in proactive care, including critical care coordination, is under the purview of Medicare Part B, but is generally not reimbursed.  This is ironic since the result of such care coordination is a decrease in unnecessary hospitalizations, as overall quality is improved.  This results in  significant savings to Medicare Part A, more than enough savings to offset the costs of the care delivered.  This money is not made available to Part B, however, under the dominant fee for service system.   Over the past 15 years there has been a clear demonstration by a number of organizations that care coordination can significantly improve clinical outcomes for ESRD patients and constrain the costs of care.  In order to carry out these programs, however, such groups as Kaiser, DaVita and Fresenius have had to rely on contracting with commercial insurers (Medicare Advantage programs) or participating in CMS Demonstration projects.  There have been two such Demos in the past decade, both showing improved outcomes and constrained costs, but there is no plan from CMS to now extend such programs to the full
ESRD population.

The latest iteration of care coordination focusing on improving quality and controlling costs is ACOs (accountable care organizations).  A construct contained in the Affordable Care Act, the recently published preliminary rules unfortunately make ACOs focused on ESRD patients difficult if not impossible to carry out.  While the new Center for Medicare and Medicaid Innovation (CMMI) may be another vehicle for a new care coordination pilot in ESRD, the renal community needs to be vocal in asking:  Why another Demo?  Who will advocate for the ESRD patient in general ACOs?  Why is it so difficult to get the attention of policy makers for this vulnerable, costly population, particularly when a care delivery model that could have significant positive impact has already been proven to work?

It’s time for us to redouble our efforts to push decision makers to do what is right for our patients.

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

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Recently CMS convened a series of technical expert panels (TEPs) that were charged with recommending new clinical performance measures (CPMs) that could be submitted to the National Quality Forum (NQF) for endorsement.  As a member of the fluid management TEP I was able to follow the process from start to finish, and we should all be concerned about the process and the way we need to drive better quality for our patients.

The purpose of a CPM is to change behavior on the part of a practitioner.  That is, the CPM is derived from rigorous evidence in the literature, and is then constructed to set a target for a particular outcome based on the evidence.  For example, if best evidence suggests that patients have better survival with Kt/V≥1.2, the CPM would be the fraction of patients achieving this goal, and targets would be set based on current performance and projections of what should be desirable and achievable.

When the four TEPs completed their work, however, it became clear that the lack of rigorous evidence in the literature severely limited what CPMs could be based on solid evidence.  Despite this fact, and the recommendations of a separate data TEP- a group that opined on the availability of the data needed to calculate performance on each CPM proposed- that there were significant gaps in this area, 44 measures were forwarded to NQF for consideration.  A mere handful were endorsed since NQF has an appropriately high bar that CPMs must meet, particularly regarding quality of the evidence base, before they will be endorsed.

Many of my colleagues who participated in the process expressed disappointment or even outrage that the work of experts could be rejected by NQF.  It was clear to me, however, that since CPMs are used by regulators and payers and others to judge the performance of providers it is essential that such measures truly are based on evidence, and unfortunately many of ours were not or the evidence was scant and weak.

Thus the conundrum- does the lack of evidence that meets CPM standards mean that we are now paralyzed in driving the quality agenda forward?  I think we need to step back and think more clearly about the difference between measuring quality for accountability purposes and driving quality improvement for patients.  This to me is best understood using the OJ Simpson analogy.  As many of you will recall this renowned football player was accused of brutally murdering his wife and her friend.  Mr. Simpson was acquitted in the criminal case but lost in a civil case brought by the victim’s family.  In the former, to be convicted in criminal court there needed to be proof beyond a reasonable doubt while in the latter a preponderance of the evidence was sufficient.

We need to ask ourselves, although CPMs need to meet the “proof beyond a reasonable doubt” standard, quality improvement initiatives do not, in my view.  The art of medicine mandates that clinicians make their best judgment, based on whatever evidence is available, and on the balance between risk and benefit, on what should be tried and what shouldn’t.  This approach should be applied not only to the care of individual patients, but to populations as well.  Each of us would be wise to review the 44 CPM recommendations that came out of the TEPs and consider how to apply them to our dialysis populations- they may not meet the proof beyond a reasonable doubt standard, but if implemented they will do more to help improve patient outcomes than will waiting for the next big randomized controlled trial.

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

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I was in Washington, DC last month at the DaVita Board of Director’s meeting. My presentation to the Clinical Performance Committee of the Board was very upbeat—2010 was another great year for our patients with improvements in most intermediate outcomes, and continued improvement in survival rates.  Some of the clinical outcomes were truly spectacular; day 90+ catheter rate has fallen 27% since 2007 and influenza vaccinations reached 90% in the first quarter of 2011. I was very proud that our DaVita teams, caregiver teammates, Medical Directors, attending physicians, and all of the great support people in the field and at corporate, not only collaborated to make this happen, but were able to celebrate these remarkable achievements.

I was then able to present some of the data from our Seabiscuit’s program, the systematic approach to identifying chronically underperforming facilities based on clinical scores on the DaVita Quality Index (DQI)- these are facilities in the lowest 20% of DQI scores for at least 6 months.  As we presented at ASN last year, DQI a composite quality score, is a powerful predictor of facility level mortality and hospitalizations. Remarkably, the vast majority of the Seabiscuit’s facilities significantly improved their scores by intensely focusing on the underlying cause of their poor performance, usually the lack of facility leadership, such as a weak Facility Administrator or Medical Director, or both. I somewhat glibly stated to the Board that the key to improving these facilities had generally been bringing in new leadership; then one of the Board members, someone without any clinical background, asked a marvelous question. “What do these new people say they have done to improve the quality of care in the facility?”  Of course this is exactly what we should be asking so that we can share these pearls of information with all of our facilities.  I couldn’t answer the question, however, since we hadn’t asked it.

What is the “secret sauce” that makes a dialysis facility great? Is it clinically knowledgeable teammates, low staff turnover, a true team mentality and work ethic focused on the patient and the patient experience?  We intend to find out by going back to the facilities that were improved by focused, corrective action and asking them those questions. However, in the meantime, are anxious to hear from others about their sense of what it takes to be the best.

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

Kidney disease has become a condition of epidemic proportions throughout the world. Afflicted patients have high morbidity and mortality, and the costs of care to individuals, governments and society are staggering. I have had the fortune to see the discipline of nephrology grow from one where dialysis and transplantation were scarce, prior to 1972, to the present where the growing needs of aging populations are straining our ability to deliver high quality, cost-effective care. Over the next weeks, months and years, I hope that this blog will stimulate thought about how we can fulfill our mission as physicians, to always think of what is best for patients first, while being responsible stewards of the public trust and resources which enable us to carry out this mission.

The global nature of this challenge came sharply into focus to me on a recent trip to Singapore.  I went there to visit two large academic hospitals, Singapore General Hospital and National University Hospital, as well as to see some of the dialysis facilities in that country. I was struck by the highly sophisticated state of medical care in Singapore, the access to care for needy and wealthy citizens alike, and the insightful comments and questions after my presentations. I realized that I was guilty, as many of us are in the US, of having preconceptions that care was inferior elsewhere, despite statistics that would suggest the contrary. In fact, in Singapore, fewer than 10% of patients dialyze through a percutaneous catheter, and intermediate outcomes for anemia, dialysis adequacy, and so on are quite similar, if not better than ours.

The population in Singapore are aging and the prevalence of diabetes and hypertension are increasing.  The impact is already being seen in a renewed strain on the healthcare system, a rise in the appearance of CKD, and an increase in the incident ESRD rate. Older, sicker patients needing dialysis in a system with restrained resources. Sound familiar?

As author and NY Times foreign affairs columnist Thomas Friedman has pointed out in his bestselling book, “The World Is Flat,” our world is indeed becoming flat. For healthcare and its challenges this may be coming more slowly, but it is definitely happening. Re-energizing research into the causes and prevention of CKD/ESRD as well as accelerating current research to emulate the function of natural kidneys will become even more important as this global epidemic continues to unfold. The development of innovative, more cost-effective approaches to preventing and treating ESRD needs to occur so that not only the length, but the quality of life for these vulnerable patients can be enhanced.

“There is no substitute for face-to-face reporting and research,”
Thomas Friedman, author of The World Is Flat

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD