Geography and ESRD Care

Abstract

In 2004, the Centers for Medicare and Medicaid Services (CMS) made a landmark change in the way nephrologists were reimbursed for outpatient dialysis visits for the first time in over 30 years. The Final Rule, as it was called, changed reimbursement for dialysis outpatient assessment from a capitated monthly visit to a graded reimbursement based on the number of times per month a patient was seen in the outpatient setting. These ESRD-related visits, defined by the new "G codes," allow for reimbursement for 1 visit, 2-3 visits, or $4 visits per month. Visits must be provided face to face by a nephrologist or other provider and can occur in the dialysis unit or other outpatient settings (1). Before the Final Rule, much discussion occurred among dialysis providers, nephrologists, and nephrology practices because of concerns that acceptance of this rule would have adverse effects on ESRD patient care due to increased requirements for dialysis unit rounding.Before the ruling, little was known regarding the association of frequency of dialysis rounding and outcomes. Several observational studies reported that increased frequency of dialysis patient visits by nephrologists was associated with several positive outcomes, including achievement of some clinical performance targets (albumin and dialysis adequacy [Kt/V], and total number of improved performance measures) (2), satisfaction with the nephrologist, and patient adherence (3). However, increased frequency was not associated with improved short-term outcomes such as fewer hospitalizations, better quality of life, or overall satisfaction with care (3). Conversely, increased frequency of "sit-down" team rounds with nursing staff, social workers, and nutritionists in the dialysis unit was associated with better clinical performance measures (albumin level), fewer hospitalizations (incidence rate ratio, 0.68; 95% confidence interval [95% CI], 0.51 to 0.91), decreased number of hospital days, and improved survival (hazard ratio, 0.71; 95% CI, 0.53 to 0.95) compared with units with fewer reported sit-down team rounds (4).Since the Final Rule went into effect, recent studies have evaluated the association of dialysis patient visits and outcomes. Mentari and colleagues evaluated changes in quality of care and health-related quality of life before and after the rule went into effect and found that patient visits increased from 1.5 to 3.14 (P,0.001) and the percentage of patients not seen during the month decreased from 16.6% to 5.1% (P,0.001); however, there were no differences in Kt/V, albumin, hemoglobin, phosphorus, calcium, catheter use, hospitalizations, compliance with dialysis treatment prescription, or patient satisfaction (5). Using a larger national sample of data from the US Renal Data System (USRDS), Slinin and colleagues evaluated provider-patient visit frequency and hemodialysis outcomes, and found no difference in all-cause mortality; however, patients who had four provider visits per month had a 4% lower risk of first hospitalization, or hospitalizations for...