Erickson Kevin F, Winkelmayer Wolfgang C, Chertow Glenn M, Bhattacharya Jay
Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, 2002 Holcombe Blvd, Mail Code 152, Houston, TX 77030. E-mail:
Am J Manag Care. 2016 Jun 1;22(6):e215-23.
Patients with end-stage renal disease can receive dialysis at home or in-center. In 2004, CMS reformed physician payment for in-center hemodialysis care from a capitated to a tiered fee-for-service model, augmenting physician payment for frequent in-center visits. We evaluated whether payment reform influenced dialysis modality assignment.
Cohort study of patients starting dialysis in the United States in the 3 years before and the 3 years after payment reform.
We conducted difference-in-difference analyses comparing patients with traditional Medicare coverage (who were affected by the policy) to others with Medicare Advantage (who were unaffected by the policy). We also examined whether the policy had a more pronounced influence on dialysis modality assignment in areas with lower costs of traveling to dialysis facilities.
Patients with traditional Medicare coverage experienced a 0.7% (95% CI, 0.2%-1.1%; P = .003) reduction in the absolute probability of home dialysis use following payment reform compared with patients with Medicare Advantage. Patients living in areas with larger dialysis facilities (where payment reform made in-center hemodialysis comparatively more lucrative for physicians) experienced a 0.9% (95% CI, 0.5%-1.4%; P < .001) reduction in home dialysis use following payment reform compared with patients living in areas with smaller facilities (where payment reform made in-center hemodialysis comparatively less lucrative for physicians).
The transition from a capitated to a tiered fee-for-service payment model for in-center hemodialysis care resulted in fewer patients receiving home dialysis. This area of policy failure highlights the importance of considering unintended consequences of future physician payment reform efforts.
终末期肾病患者可在家中或中心接受透析治疗。2004年，医疗保险和医疗补助服务中心（CMS）将中心血液透析治疗的医生支付方式从按人头付费改为分层服务收费模式，增加了对频繁进行中心透析治疗的医生支付费用。我们评估了支付方式改革是否影响透析方式的选择。
对支付方式改革前3年和改革后3年在美国开始透析治疗的患者进行队列研究。
我们进行了差分分析，将有传统医疗保险覆盖的患者（受该政策影响）与有医疗保险优势计划的其他患者（不受该政策影响）进行比较。我们还研究了该政策在前往透析设施成本较低的地区对透析方式选择是否有更显著的影响。
与有医疗保险优势计划的患者相比，支付方式改革后，有传统医疗保险覆盖的患者接受家庭透析的绝对概率降低了0.7%（95%CI，0.2%-1.1%；P = 0.003）。与居住在透析设施较小地区的患者（支付方式改革使中心血液透析对医生来说利润相对较低）相比，居住在透析设施较大地区的患者（支付方式改革使中心血液透析对医生来说利润相对较高）在支付方式改革后接受家庭透析的比例降低了0.9%（95%CI，0.5%-1.4%；P < 0.001）。
中心血液透析治疗从按人头付费向分层服务收费支付模式的转变导致接受家庭透析的患者减少。这一政策失败领域凸显了考虑未来医生支付方式改革努力的意外后果的重要性。
