Who could have guessed that one day physicians would be paid based on the outcomes of patients under their care? This is the imminent reality in nephrology. As part of the Medicare Improvements for Patient and Providers Act (MIPPA), dialysis clinics will have incentives to improve outcomes, including adjustable composite rates.

Since 1983, Medicare has paid for dialysis using a composite rate that includes reimbursement for dialysis treatment, clinic staff, ancillary items such as blood tubes and dialysate fluid, and some medications.

The upcoming MIPPA system will expand the bundled coverage so that there will be even fewer “separately billable” items. Some believe that the new bundling system, due to start in 2011, will be the most dramatic change in the dialysis payment system since the Medicare end-stage renal disease program began in 1973.

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Others, however, are more concerned with the so-called “quality incentives,” with 2% of the bundled payment withheld as a default. Dialysis centers with a superior constellation of outcome measures will be entitled to get this marginal incentive back.

What is less clear is the definition of “good” outcome measures for a dialysis patient. Take anemia management, for instance. Is a hemoglobin level in the 10 to 12 g/dL range a good outcome measure? Does it matter how often a patient’s hemoglobin cycles above or below the target range, as long as the three-month rolling average is within the target? Does medication dose play a role when hemoglobin remains within the target range? Will a hemoglobin level that is usually above 12 g/dL, even without medication, be considered unwarranted? 

Defining good outcome measures for the mineral and bone disorders—where there is even less consensus—is probably more challenging. Should a good serum phosphorus range be defined as 3.5 to 5.5 mg/dL or just any phosphorus below 5.5 mg/dL, even when these levels are in patients with malnutrition?

These discussions reminds me of my approach to my pre-school daughter, who knows if she does a “good thing,” she gets a “good child score.” Although I am smart enough to be vague on the definition of the “good thing,” she never ceases to amaze me with her ongoing quest to define all her acts as “good, ”even when she draws happy faces on the recently painted walls.

Dr. Kalantar-Zadeh is Associate Professor of Medicine and Pediatrics, and Director, Dialysis Expansion & Epidemiology, Harbor-UCLA Division of Nephrology & Hypertension. He is the Medical Director for Nephrology at Renal & Urology News.