Is there “Cherry Picking” in the ESRD Program? Perceptions from a Dialysis Provider Survey

Abstract

Background and objectives: Changes in ESRD reimbursement policy, including proposed bundled payment, have raised concern that dialysis facilities may use "cherry picking" practices to attract a healthier, better insured, or more adherent patient population.Design, setting, participants, & measurements: As part of a national survey to measure beliefs about drivers of quality in dialysis, respondents were asked about their perceptions of cherry picking, including the frequency and effect of various cherry picking strategies on dialysis outcomes. We surveyed a random sample of 250 nurse members of the American Nephrology Nurses Association, 250 nephrologist members of the American Medical Association, 50 key opinion leaders, and 2000 physician members of the Renal Physicians Association. We tested hypothesized predictors of perception, including provider group, region, age, experience, and the main practice facility features.Results: Three-quarters of respondents reported that cherry picking occurred "sometimes" or "frequently." There were no differences in perceptions by provider or facility characteristics, insurance status, or health status. In multivariable regression, perceived cherry picking was 2.8-and 3.5-fold higher in the northeast and Midwest, respectively, versus the west. Among various cherry picking strategies, having a "low threshold to 'fire' chronic no-shows/late arrivers," and having a "low threshold to 'fire' for noncompliance with diet and meds" had the largest perceived association with outcomes.Conclusions: Under current reimbursement practices, dialysis caregivers perceive that cherry picking is common and important. An improved understanding of cherry picking practices, if evident, may help to protect vulnerable patients if reimbursement practices were to change.

Both Patient and Facility Contribute to Achieving the Centers for Medicare and Medicaid Services' Pay-for-Performance Target for Dialysis Adequacy

“…Recent surveys of dialysis staff including physicians, nurses, and medical directors indicated that at least three fourths of respondents felt that "cherry picking" occurred sometimes or frequently in dialysis units, and the practice of excluding chronic late arrivals/no shows was considered to have the strongest impact on dialysis outcomes. 16 With a 2% cut in payment legislated by Congress for 2011 and with additional reductions for failing to meet the URR quality indicator under the QIP, we suspect that cherry picking will increase, widening the disparity in care provided to this high-risk subgroup of patients.…”

The Evolving Ethics of Dialysis in the United States

“…The strategy of rationing medical resources has developed a negative connotation, and the Affordable Care Act explicitly rejects it (53). However, others suggest that we are already implicitly rationing by "cherry picking" patients who show up to clinic appointments or are adherent to medical regimens, neglecting those who may fail to do so for reasons such as limited finances, cognitive disability, or comorbidity (54,55). As the early experience of the Seattle Artificial Kidney Center demonstrates, if rationing must play a role in allocation of limited resources, criteria need to be transparent and explicit to avoid unintentional discrimination.…”

The Ethics of Chronic Dialysis for the Older Patient

“…With bundling of care, previous incentives to offer hemodialysis to as many patients as possible will be replaced with a disincentive to dialyze high-risk patients. This is concerning because hemodialysis practices are sensitive to financial incentives and cherry picking (78,79). In other countries, dialysis may again become a target for explicit and implicit age-based rationing according to cost and lack of demonstrated benefit (17).…”