Three researchers have published an editorial calling the Centers for Medicare and Medicaid Services (CMS) to address financial disincentives that discourage physicians from providing care for patients with chronic kidney disease, but who are not yet on dialysis.

CMS reimburses nephrologists a monthly capitated payment (MCP) ranging from about $188 to $388 for overseeing outpatient dialysis care, Jeffrey S. Berns, MD, of the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, and his coauthors wrote in the Journal of the American Society of Nephrology. For patients with CKD not on dialysis, however, CMS and other insurers pay for office visits on a fee-for-service basis, with the most complex return office visit reimbursed at about $148 a visit. “Thus, the MCP for dialysis is substantially higher than the payments for CKD office visits,” they wrote.

“There are no financial incentives or quality measures encouraging providers to maximize their efforts to slow CKD progression or delay initiation of dialysis unless truly necessary, even though doing so would decrease health costs and improve quality of life for many patients,” Dr Berns and his co-authors wrote.

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Patients with advanced CKD, particularly those approaching end-stage renal disease (ESRD), are complex and usually need a multidisciplinary care strategy requiring a substantial amount of investment and infrastructure. “However, because caring for patients on dialysis reimburses physicians more than caring for patients with CKD, physicians may not feel incentivized to make this investment.”

Dr Berns and his coauthors, Tonya L. Saffer, MPH, of the National Kidney Foundation in New York, and Eugene Lin, MD, MS, of the University of Southern California in Los Angeles, suggest that CMS initially launch a CKD payment reform pilot program for patients most likely to benefit and who are not in imminent need of renal replacement therapy. “Realigning payment incentives to focus on the health of patients with CKD has the potential to benefit CMS by reducing costs, nephrology providers by enhancing their ability to care for patients with CKD, and most importantly, patients as recipients of comprehensive, coordinated, and multidisciplinary care that avoid dialysis until essential,” the authors concluded.


Berns JS, Saffer TL, Lin E. Addressing financial disincentives to improve CKD care. J Am Soc Nephrol. 2018; published online ahead of print.