In addition, the young, well-educated, highly skilled chronic dialysis patient with few comorbidities became increasingly less likely to return to work as time passed, perhaps as levels of aspiration and optimism declined.3 Efforts to capture some return on the public instrument may have driven much of the change in the ESRD program over the past 10 years; for example, these changes now encourage transplantation over maintenance dialysis. Initially, maintenance dialysis was provided almost exclusively in the hospital setting. As the procedure became more routine, independent or "freestanding" dialysis centers began
e success of the independent centers is understandable in view of a 1975 congressional study showing annual costs for clinic or freestanding dialysis to be 14,000-20,000, about half of the 30,000 and up cost for care provided in hospital-based centers. In 1983, Medicare began to capitate the care of dialysis patients, further stimulating use of freestanding clinics, with their greater efficiencies associated with a narrow focus. The 1983 capitation move, combined with payment cuts put in place in 1981, stimulated cost-cutting measures at the dialysis clinics and promoted the growth of dialysis chains. Efforts to cut costs also led to the reuse of dialysis kidneys," the plastic filters at the heart of the dialysis machine's function. This now appears to be a relatively safe procedure, but, when reuse was first instituted, the need for meticulous cleaning between uses was not fully understood and quality may have suffered. Other indicators continue to be quoted by investigators as suggestive of decreasing quality in both freestanding and hospital-based dialysis units. The most often observed measure is the 1-to-3 staff/patient 3 mix of 1983 that changed to 1-to-5 by 1985. The concern for quality led the Department of Health and Human Services Inspector General to state, "We have built [ESRD] programs without proper controls, on the faith that the professionals would police themselves. That, I can assure you, is flawed judgment. Early in the ESRD program, Congress began to look for mechanisms to stimulate alternative treatment programs. Initially promising alternatives to staff-performed dialysis were developed for both hospital and home settings, but they have not captured a large proportion of the chronic dialysis population. As noted, the payment system for hospital, freestanding, and home dialysis was restructured in 1981, and in 1983 HCFA further reduced Medicare payments for freestanding and The same 1975 congressional study showed that patients could be maintained at home, with then-available home dialysis technology, for only 4,000-6,000 per year. Self-administered home hemodialysis is the most popular alternative to dialysis performed by professional staff. Dialysis was first performed in a home setting in Boston in 1964 and quickly grew in scope; up to 75 percent of dialysis patients in some states were using it by 1969.' Home dialysis was favored by Congress because of the apparent cost savings, but this segment of the ESRD program fell to 15 percent of patients by 1978. Policy decisions had inadvertently put in place inphysicians to favor freestanding dialysis centers. Equipment, operational costs, physician fees, dialysis assistant costs, and the waiting period for entitlement have all been blamed for the shift away from home care. Changes in payment patterns beginning in 1981 helped to reverse this trend, but in 1985 home hemodialysis accounted for only 5.1 percent of ESRD patients, and this declined to 3.8 percent in 1987. Expectations are for this segment of the ESRD program to remain stable at best, and recent attacks on the paymesnt system to develop to encourage home dialysis may result in continued reductions in patient selection of this mode of therapy. In February 1989, HCFA issued proposed guidelines for limiting the annual amount to be allowed for supplies and equipment used in home dialysis. The proposed limit would be based on a national average composite rate per dialysis treatment. Continuous Ambulatory Peritoneal Dialysis and its variants promised lower costs, improved return-to-work rates, and a greater sense of well-being for patients. Recent analysis, however, suggests that early reports of differences in quality of life may have been due to patients' characteristics influencing their selection of therapy type, rather than to the therapy's intrinsic benefits. Original predictions of cost savings are now debated, and were probably overstated. Whatever the causes, poor patient participation in dialysis alternatives is evident. In 1985, all alternative therapies accounted for 22 percent of the total dialysis population. By 1987, this number had declined to 20 percent.6 In Part II of this article, we will shift our attention to kidney transplantation and explore some economic comparisons between transplantation and dialysis.
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|Title Annotation:||End State Renal Disease; Medicare's ESRD Program, part|
|Author:||Long, Hugh W.|
|Date:||Mar 1, 1989|
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