Delivering a “New Deal” of Kidney Health Opportunities to Improve Outcomes Within the Veterans Health Administration

Crowley, Susan T.; Murphy, Katherine

doi:10.1053/j.ajkd.2018.01.056

Cited by 6 publications

(6 citation statements)

References 29 publications

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“…Our finding of lower mortality among veterans dialyzing in dual settings further underscores the importance and promise of improving VA partnerships with community providers to support treatment, coordination, and transitions of chronic dialysis care between VA and non-VA systems. 7 There are study limitations that should be noted. First, results may not generalize to veterans receiving dialysis through Medicare Advantage or private insurance (approximately 9000 veterans) because we were not able observe dialysis claims from these sources, or to veterans initiating dialysis after 2011.…”

Section: Discussionmentioning

confidence: 99%

“…Most VA-enrolled veterans receive dialysis under Medicare. 6 Many of the remaining patients receive treatment via VA-PC under their local authority, when VA facilities are unable to meet veteran demand for maintenance dialysis (e.g., insufficient capacity or geographic inaccessibility), 7 and only approximately 4% receive dialysis within the VA. This system of VA-outsourced, non-VA dialysis under VA-PC was in place before the introduction of the Veterans Choice Act, the VA Mission Act, and the new VA Community Care Program, which expanded access to community care for a wide range of services but explicitly excludes chronic dialysis.…”

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confidence: 99%

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Survival among Veterans Obtaining Dialysis in VA and Non-VA Settings

Wang

Stechuchak

Berkowitz

et al. 2018

JASN

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Background Outcomes of veterans with ESRD may differ depending on where they receive dialysis and who finances this care, but little is known about variation in outcomes across different dialysis settings and financial arrangements. MethodsWe examined survival among 27,241 Veterans Affairs (VA)-enrolled veterans who initiated chronic dialysis in 2008-2011 at (1) VA-based units, (2) community-based clinics through the Veterans Affairs Purchased Care program (VA-PC), (3) community-based clinics under Medicare, or (4) more than one of these settings ("dual" care). Using a Cox proportional hazards model, we compared all-cause mortality across dialysis settings during the 2-year period after dialysis initiation, adjusting for demographic and clinical characteristics. ResultsOverall, 4% of patients received dialysis in VA, 11% under VA-PC, 67% under Medicare, and 18% in dual settings (nearly half receiving dual VA and VA-PC dialysis). Crude 2-year mortality was 25% for veterans receiving dialysis in the VA, 30% under VA-PC, 42% under Medicare, and 23% in dual settings. After adjustment, dialysis patients in VA or in dual settings had significantly lower 2-year mortality than those under Medicare; mortality did not differ in VA-PC and Medicare dialysis settings.Conclusions Mortality rates were highest for veterans receiving dialysis in Medicare or VA-PC settings and lowest for veterans receiving dialysis in the VA or dual settings. These findings inform institutional decisions about provision of dialysis for veterans. Further research identifying processes associated with improved survival for patients receiving VA-based dialysis may be useful in establishing best practices for outsourced veteran care.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Survival among Veterans Obtaining Dialysis in VA and Non-VA Settings

Wang

Stechuchak

Berkowitz

et al. 2018

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“…Veterans with ESKD are one of the fastest growing and most costly segments of the veteran population (2)(3)(4)(5)(6). Because of limited capacity of VA dialysis facilities and the need for veterans to receive treatment close to home, VA has a long history of reliance on community dialysis providers that predates recent legislation to promote access to community care for veterans (7,8). Over time, the proportion of veterans with ESKD receiving community-based dialysis has increased from 56% in 2008 to 77% in 2017.…”

Section: Introductionmentioning

confidence: 99%

Association of VA Payment Reform for Dialysis with Spending, Access to Care, and Outcomes for Veterans with ESKD

Wang

Swaminathan

Corneau

et al. 2020

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Background and objectivesBecause of the limited capacity of its own dialysis facilities, the Department of Veterans Affairs (VA) Veterans Health Administration routinely outsources dialysis care to community providers. Prior to 2011—when the VA implemented a process of standardizing payments and establishing national contracts for community-based dialysis care—payments to community providers were largely unregulated. This study examined the association of changes in the Department of Veterans Affairs payment policy for community dialysis with temporal trends in VA spending and veterans’ access to dialysis care and mortality.Design, setting, participants, & measurementsAn interrupted time series design and VA, Medicare, and US Renal Data System data were used to identify veterans who received VA–financed dialysis in community-based dialysis facilities before (2006–2008), during (2009–2010), and after the enactment of VA policies to standardize dialysis payments (2011–2016). We used multivariable, differential trend/intercept shift regression models to examine trends in average reimbursement for community-based dialysis, access to quality care (veterans’ distance to community dialysis, number of community dialysis providers, and dialysis facility quality indicators), and 1-year mortality over this time period.ResultsBefore payment reform, the unadjusted average per-treatment reimbursement for non–VA dialysis care varied widely ($47–$1575). After payment reform, there was a 44% reduction ($44–$250) in the adjusted price per dialysis session (P<0.001) and less variation in payments for dialysis ($73–$663). Over the same time period, there was an increase in the number of community dialysis facilities contracting with VA to deliver care to veterans with ESKD from 19 to 37 facilities (per VA hospital), and there were no changes in either the quality of community dialysis facilities or crude 1-year mortality rate of veterans (12% versus 11%).ConclusionsVA policies to standardize payment and establish national dialysis contracts increased the value of VA–financed community dialysis care by reducing reimbursement without compromising access to care or survival.

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“…Dialysis care is a covered benefit for all veterans enrolled in the Department of Veterans Affairs (VA), and the majority of these enrollees can qualify for the Medicare ESKD program regardless of age (1). Because of the VA's limited dialysis capacity (74 clinics with outpatient dialysis capability) (2), most of the 13,000 veterans with ESKD who initiate dialysis each year do so in the community, financed mainly by either Medicare or the VA (1). Over the past decade, the proportion of veterans with ESKD turning to the VA for dialysis services has grown such that roughly half of all veterans with prevalent ESKD now rely on the VA to either directly deliver dialysis or, more commonly, to purchase their dialysis care in a non-VA setting (3).…”

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confidence: 99%

“…As reported by Streja et al (6), a higher proportion of VA users have an arteriovenous access at dialysis initiation, suggesting better pre-ESKD nephrology care. In addition, lower mortality risk among VA users may reflect advantages of VA treatment for discordant conditions (2).…”

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confidence: 99%