Dialysis :: As dialysis becomes a target of cost control, doctor-patient relationship is key

As medical, economic, and policy trends converge to alter the way dialysis care is organized and financed, protecting the unique relationship between dialysis patients and the kidney specialists who direct their care is a top priority, according to a special feature in the July Journal of the American Society of Nephrology.

Dr. Jonathan Himmelfarb of the Maine Medical Center and colleagues review some of the interconnected trends that are changing the face of dialysis care in the United States. Dialysis has had a major impact on U.S. health care costs, particularly since Congress established Medicare entitlement for treatment of end-stage renal disease (ESRD) in 1972. At that time, the estimated U.S. incidence of ESRD was 40 cases per million persons per year?roughly 12 percent of the current actual rate.

Improvements in efficiency and technology have contributed to lowering the cost of providing a single dialysis treatment, and to continued profits for dialysis providers. At the same time, the overall costs of dialysis to the U.S. health care system have risen steadily?the result of “geometric expansion” in the number of ESRD patients.

Various approaches have been proposed to increase the value while lowering the costs of dialysis care. Under “pay for performance” plans, doctors and dialysis providers would be paid more for delivering higher-quality care. However, there is debate over how such plans would work, and particularly how high-quality care would be defined. Medicare may soon “bundle” payments for ESRD care to include drugs and other services that are currently billed separately.

Meanwhile, the number of new nephrologists in training seems inadequate to meet the growing demand. This is a special concern given the increasing emphasis on earlier recognition and specialist treatment of patients with chronic kidney disease.

With recent corporate acquisitions, two large companies now share about 70 percent of the national dialysis market. Consolidation has brought progress in some areas, such as accountability, standardization of care, and quality improvement. However, nephrologists, nurses, and other members of the patient-care team may find themselves caught in the middle as they seek to balance their duty to provide the best possible patient care against the competing interests of multiple stakeholders?corporate leadership and managers, stockholders, payers, and others?with a vested interest in dialysis care.

All of these factors have the potential to dramatically alter the relationship between the doctor and patients in the dialysis unit, Dr. Himmelfarb and coauthors write. “If the nephrologist becomes consumed with simply conforming to process and meeting laboratory quality metrics?there is a real danger that [he or she] will lose sight of the patient as an individual.”

In the face of these shifting trends, Dr. Himmelfarb and colleagues urge a renewed focus on the relationship between nephrologists and dialysis patients. “The nephrologist should be the final arbiter of the complex interaction between the corporate provider, statutory regulators, and the pharmaceutical companies as they all relate directly to patient care,” the authors write. To help ensure independence from competing pressures, they also recommend that nephrologists’ medical fees not be included in new plans for “bundled” Medicare payments.

Most importantly, Dr. Himmelfarb and coauthors urge their fellow specialists to take an active role in ensuring that dialysis care remains focused on the patient. “It is essential that in the coming era, nephrologists strive vigorously to maintain the primacy of the physician-patient relationship, and maintain the integrity and credibility of the patient-centered value system and therapeutic environment,” they conclude. “To accomplish this, nephrologists must be willing to play an active role in the redesign of care models and payment systems across the spectrum of kidney disease.”

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