Hemodialysis Hospitalizations and Readmissions: The Effects of Payment Reform.

Erickson KF1, Winkelmayer WC2, Chertow GM3, Bhattacharya J4.

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Abstract

BACKGROUND:

In 2004, the Centers for Medicare & Medicaid Services changed reimbursement for physicians and advanced practitioners caring for patients receiving hemodialysis from a capitated to a tiered fee-for-service system, encouraging increased face-to-face visits. This early version of a pay-for-performance initiative targeted a care process: more frequent provider visits in hemodialysis. Although more frequent provider visits in hemodialysis are associated with fewer hospitalizations and rehospitalizations, it is unknown whether encouraging more frequent visits through reimbursement policy also yielded these benefits.

STUDY DESIGN:

We used a retrospective cohort interrupted time-series study design to examine whether the 2004 nephrologist reimbursement reform led to reduced hospitalizations and rehospitalizations. We also used published data to estimate a range of annual economic costs associated with more frequent visits.

SETTING & PARTICIPANTS:

Medicare beneficiaries in the United States receiving hemodialysis in the 2 years prior to and following reimbursement reform.

PREDICTOR:

The 2 years following nephrologist reimbursement reform.

OUTCOMES:

Odds of hospitalization and 30-day hospital readmission for all causes and fluid overload; US dollars.

RESULTS:

We found no significant change in all-cause hospitalization or rehospitalization and slight reductions in fluid overload hospitalization and rehospitalization following reimbursement reform; the estimated economic cost associated with additional visits ranged from $13 to $87 million per year, depending on who (physicians or advanced practitioners) spent additional time visiting patients and how much additional effort was involved.

LIMITATIONS:

Due to limited information about how much additional time providers spent seeing patients after reimbursement reform, we could only examine a range of potential economic costs associated with the reform.

CONCLUSIONS:

A Medicare reimbursement policy designed to encourage more frequent visits during outpatient hemodialysis may have been costly. The policy was associated with fewer hospitalizations and rehospitalizations for fluid overload, but had no effect on all-cause hospitalizations or rehospitalizations.

KEYWORDS:

Hemodialysis; Quality Incentive Program (QIP); economic incentives; end-stage renal disease (ESRD); fee-for-service; fluid overload; health care costs; health policy; pay for performance (P4P); payment reform; physician reimbursement; physician visit frequency; rehospitalization