More than 100,000 Americans develop end-stage renal disease every year, which, due to a significant shortage of kidneys available for transplantation, requires the majority of patients to seek treatment through dialysis. In a study published recently in The American Journal of Managed Care, Baylor College of Medicine’s Dr. Kevin F. Erickson discusses physician reimbursement reform and its effect on patient recommendations for in-center dialysis as opposed to at-home dialysis.

The passage of the Affordable Care Act and the recent repeal of Medicare’s Sustainable Growth Rate have resulted in pay-for-performance (P4P) initiatives that increasingly tie physician payment to performance.

“Recent healthcare reform focuses on developing new reimbursement policies to encourage certain activities for physicians, and when these policies are put into place, it is important that we understand whether they worked, and whether they resulted in any unintended consequences,” said Erickson, assistant professor of medicine in the section of nephrology at Baylor. “This study highlights the need to understand and monitor for unintended consequences of ongoing reimbursement reform.”

Enhancing quality of life

For the majority of patients with kidney disease who are receiving dialysis, the decision to receive care in the home versus in a dialysis center should be a personal, educated decision made with consideration from physicians and families.

“Day-to-day life is very different for patients administering dialysis at home compared to those who go to a dialysis center to receive therapy,” said Erickson. “Often, at-home dialysis creates a higher quality of life, providing more flexibility in treatment schedules and a more comfortable environment.”

Erickson developed the study to determine if P4P reimbursements designed to encourage frequent physician visits to patients receiving in-center dialysis had the unintended consequence of leading some physicians to place more patients in an in-center treatment plan in order to capitalize on higher reimbursement from frequent in-center visits.

To test this theory, Erickson compared the likelihood of patients to start in-home dialysis before versus after the policy implementation in populations that were and were not affected by the policy.

Patients with Traditional Medicare coverage who were affected by the reimbursement policy were found to be less likely to do at-home dialysis following the policy reform than those on Medicare Advantage who were not affected by the policy.

Additionally, patients residing in areas with larger treatment facilities were less likely to have at-home dialysis following the policy reform than those living in areas with smaller facilities. This reduction is a result of the reform making it more financially attractive to physicians to see patients who receive in-center dialysis in larger facilities.

“Our findings suggest that physicians’ decisions aligned toward the treatment option that benefitted them financially, as opposed to what may have been best for the patient,” said Erickson. “As a result, fewer patients were receiving at-home dialysis.”

Home dialysis is largely underused, and there is no evidence that one method of treatment is better in terms of health outcomes, but there are significant differences in the quality of life and home dialysis is less costly than in-center dialysis. 

Examining the unintended consequences

Erickson notes that a recent report by the Government Accountability Office examining financial barriers to home dialysis has identified physician reimbursement policy as one important area where there may be a financial disincentive to recommending home dialysis. Those findings were based on interviews from physicians, while this study provides objective evidence supporting the same concern.

This study also provides an important lesson for efforts to evaluate future P4P initiatives.

“This is a very specific choice made at a specific point in time in a patient’s course of kidney disease,” said Erickson. “It may very well require getting into the weeds of clinical decision making, with this degree of specificity, to uncover unintended consequences from payment reform that are most important to patients.”

For patients, Erickson recommends having an open conversation with family members and physicians to determine if at-home dialysis is best for them. Erickson also stresses the importance of education about at-home dialysis, as many patients simply are not aware that it is an option.

Other contributors to this work include Dr. Wolfgang C. Winkelmayer of Baylor College of Medicine, Dr. Glenn M. Chertow and Dr. Jay Bhattacharya, both with Stanford University School of Medicine.

This work was funded by the Agency for Health Research and Quality (F32 HS019178) and the National Institute of Diabetes and Digestive and Kidney Diseases (DK085446), along with support from the National Institute on Aging (R37 150127-5054662-0002) and the endowed Gordon A. Cain Chair in Nephrology at Baylor College of Medicine.