Patients who don't follow treatments hurt dialysis clinics' pay

Dialysis clinics that provide care to kidney disease patients who cannot or will not follow their prescribed treatments will be penalized under a new Medicare payment system, according to a study appearing in an upcoming issue of the Journal of the American Society Nephrology (JASN). The results suggest that the new system could widen disparities in care.

In line with today's financial changes and healthcare reforms, some health insurers offer doctors and hospitals financial rewards when they achieve, improve, or exceed certain goals. Such a pay for performance system differs from fee for service payments that encourage doctors to provide more treatments (including unnecessary ones) because payment is dependent on the quantity of care, rather than quality of care.

Recently, Medicare implemented a pay for performance program for reimbursing dialysis clinics that provide care to kidney disease patients. One goal consists of achieving adequate dialysis dose (the amount of blood that is purified) in > 96% of patients in every clinic. Therefore, clinics that don't meet the 96% goal would get financially penalized.

Navdeep Tangri, MD (at Tufts Medical Center during the study and currently at the University of Manitoba in Winnipeg, Canada) and his colleagues looked to see if patient characteristics affect whether dialysis clinic achieve this goal. By analyzing electronic health records from 10,069 dialysis patients across 173 clinics and using advanced statistical methods, the researchers found that patient characteristics—particularly how well they followed their prescribed treatments—had a tremendous impact on a facility's achievement of the pay for performance measure. For example, patients who shortened or skipped dialysis treatments or gained weight between treatments played a major role in determining whether dialysis clinics fell short of reaching their goal.

The findings indicate that dialysis clinics that provide care to a greater proportion of patients who don't follow their prescribed treatments—which tend to cluster in low-income urban areas—would get unfairly penalized under the current payment system. "We believe that these penalties may lead to cherry picking against disadvantaged patients, and therefore widen disparities in care," said Dr. Tangri. The authors noted that alternatives to penalizing clinics that care for patients with complex medical and/or social problems are needed.