Dialysis Modality Selection in the 21st Century

In the August issue of the American Journal of Kidney Diseases, Hornberger and Hirth from Stanford University School of Medicine, University of Michigan, and Cedar Associates report on how the implementation of the Medicare ESRD Prospective Payment System affected the choice of renal replacement modality for patients with end-stage renal disease (ESRD). Dr. John Hornberger (JM) discussed this article with Dr. Matthew Sparks, eAJKD Advisory Board member, and Dr. Rasheeda Hall (eAJKD), Nephrology Fellow at Duke University Medical Center.

eAJKD: Why did you choose to study the how economic factors could impact dialysis modality choice in patients with ESRD?

JH: The Medicare ESRD Prospective Payment System (PPS) was implemented in 2011 to induce providers to supply the most cost efficient dialysis services to patients. Despite evolution in home hemodialysis (HD) technologies that have made it easier to use, the actual use of home HD among eligible patients remains relatively low. We wanted to uncover why this mismatch exists. More than a decade ago, Dr. Nissenson wrote about the myriad of non-clinical factors that affect modality choice. This study was designed to evaluate whether the relative low use of home HD may be due to non-clinical factors as were addressed by Dr. Nissenson. We sought specifically to understand how implementation of the PPS might influence the dialysis provider centers’ operating income by choice of a dialysis modality.

eAJKD: You studied the financial model from the dialysis center’s perspective. Why did you select this perspective versus a societal perspective?

JH: The societal perspective provides important information to comprehensively understand the cost-benefit implications of a health technology. However, empirical research consistently shows that actual clinical and policy decisions are more often influenced by personal motivations and local-regional incentives. Our research was focused specifically on how modality choice might be influenced by financial considerations of the dialysis center. Such an analysis from the financial perspective of the provider—in this case the dialysis center—is one research method to assess whether non-clinical factors might be influencing clinical decisions. We selected “the center’s operating income” as our primary measure because it is a standard accounting measure that administrators use to assess the financial well-being of an organization.

eAJKD: What are the key findings and implications of this study?

JH: The PPS makes peritoneal dialysis (PD) look more financially attractive to dialysis organizations, using operating income as a measure. PPS does not appear to have the same effect on home HD. Prior research by Dr. Hirth found substantial state-to-state variability in the number of payments per week for home HD among Fiscal Intermediaries/Medicare Administrative Contractors (FI/MAC). The source of this variability is not well understood at this time. We speculate from our analysis that lack of standardization in payment for home HD across FI/MACs may lead to underutilization of home HD for patients in some regions where payment per week are consistently low.

eAJKD: How should clinicians respond to these findings?

JH: Home HD is a useful modality for a subset of patients with ESRD, but may be underutilized in some regions due to provider financial incentives. As stated in clinical guidelines published by professional societies, clinicians should discuss with the patient all pertinent and clinically appropriate modalities, including in-center HD, home HD, PD, and transplantation.

To view the article abstract or full-text (subscription required), please visit AJKD.org.

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