Erickson Kevin F, Winkelmayer Wolfgang C, Chertow Glenn M, Bhattacharya Jay
Section of Nephrology, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX; Center for Innovations in Quality, Effectiveness and Safety, Baylor College of Medicine, Houston, TX.
Section of Nephrology, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX.
Am J Kidney Dis. 2017 Feb;69(2):237-246. doi: 10.1053/j.ajkd.2016.08.033. Epub 2016 Nov 14.
In 2004, the Centers for Medicare & Medicaid Services changed reimbursement for physicians and advanced practitioners caring for patients receiving hemodialysis from a capitated to a tiered fee-for-service system, encouraging increased face-to-face visits. This early version of a pay-for-performance initiative targeted a care process: more frequent provider visits in hemodialysis. Although more frequent provider visits in hemodialysis are associated with fewer hospitalizations and rehospitalizations, it is unknown whether encouraging more frequent visits through reimbursement policy also yielded these benefits.
We used a retrospective cohort interrupted time-series study design to examine whether the 2004 nephrologist reimbursement reform led to reduced hospitalizations and rehospitalizations. We also used published data to estimate a range of annual economic costs associated with more frequent visits.
SETTING & PARTICIPANTS: Medicare beneficiaries in the United States receiving hemodialysis in the 2 years prior to and following reimbursement reform.
The 2 years following nephrologist reimbursement reform.
Odds of hospitalization and 30-day hospital readmission for all causes and fluid overload; US dollars.
We found no significant change in all-cause hospitalization or rehospitalization and slight reductions in fluid overload hospitalization and rehospitalization following reimbursement reform; the estimated economic cost associated with additional visits ranged from $13 to $87 million per year, depending on who (physicians or advanced practitioners) spent additional time visiting patients and how much additional effort was involved.
Due to limited information about how much additional time providers spent seeing patients after reimbursement reform, we could only examine a range of potential economic costs associated with the reform.
A Medicare reimbursement policy designed to encourage more frequent visits during outpatient hemodialysis may have been costly. The policy was associated with fewer hospitalizations and rehospitalizations for fluid overload, but had no effect on all-cause hospitalizations or rehospitalizations.
2004年，美国医疗保险和医疗补助服务中心将对为接受血液透析患者提供护理的医生和高级执业人员的报销方式，从按人头付费改为分层服务收费系统，鼓励增加面对面就诊次数。这种早期形式的按绩效付费举措针对的是一个护理流程：在血液透析中增加医护人员的就诊次数。虽然血液透析中更频繁的医护人员就诊与更少的住院和再次住院相关，但尚不清楚通过报销政策鼓励更频繁就诊是否也能产生这些益处。
我们采用回顾性队列中断时间序列研究设计，以检验2004年肾病学家报销改革是否导致住院和再次住院次数减少。我们还利用已发表的数据来估算与更频繁就诊相关的一系列年度经济成本。
在美国，报销改革前后两年内接受血液透析的医疗保险受益人。
肾病学家报销改革后的两年。
全因住院或再次住院的几率，以及所有原因和液体超负荷导致的30天内再次入院情况；美元。
我们发现报销改革后全因住院或再次住院情况无显著变化，液体超负荷导致的住院和再次住院情况略有减少；与额外就诊相关的估计经济成本每年在1300万美元至8700万美元之间，具体取决于谁（医生或高级执业人员）花费额外时间看望患者以及涉及多少额外工作量。
由于关于报销改革后医护人员看望患者额外花费多少时间的信息有限，我们只能研究与改革相关的一系列潜在经济成本。
一项旨在鼓励在门诊血液透析期间更频繁就诊的医疗保险报销政策可能成本高昂。该政策与液体超负荷导致的住院和再次住院次数减少有关，但对全因住院或再次住院情况没有影响。
