Lin Eugene, Cheng Xingxing S, Chin Kuo-Kai, Zubair Talhah, Chertow Glenn M, Bendavid Eran, Bhattacharya Jayanta
Department of Medicine, Division of Nephrology, and
Center for Health Policy and Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California.
J Am Soc Nephrol. 2017 Oct;28(10):2993-3004. doi: 10.1681/ASN.2017010041. Epub 2017 May 10.
The ESRD Prospective Payment System introduced two incentives to increase home dialysis use: bundling injectable medications into a single payment for treatment and paying for home dialysis training. We evaluated the effects of the ESRD Prospective Payment System on home dialysis use by patients starting dialysis in the United States from January 1, 2006 to August 31, 2013. We analyzed data on dialysis modality, insurance type, and comorbidities from the United States Renal Data System. We estimated the effect of the policy on home dialysis use with multivariable logistic regression and compared the effect on Medicare Parts A/B beneficiaries with the effect on patients with other types of insurance. The ESRD Prospective Payment System associated with a 5.0% (95% confidence interval [95% CI], 4.0% to 6.0%) increase in home dialysis use by the end of the study period. Home dialysis use increased by 5.8% (95% CI, 4.3% to 6.9%) among Medicare beneficiaries and 4.1% (95% CI, 2.3% to 5.4%) among patients covered by other forms of health insurance. The difference between these groups was not statistically significant (1.8%; 95% CI, -0.2% to 3.8%). Conversely, in both populations, the training add-on did not associate with increases in home dialysis use beyond the effect of the policy. The ESRD Prospective Payment System bundling, but not the training add-on, associated with substantial increases in home dialysis, which were identical for both Medicare and non-Medicare patients. These spill-over effects suggest that major payment changes in Medicare can affect all patients with ESRD.
将注射药物捆绑到单次治疗费用中支付以及支付家庭透析培训费用。我们评估了终末期肾病前瞻性支付系统对2006年1月1日至2013年8月31日在美国开始透析的患者使用家庭透析的影响。我们分析了来自美国肾脏数据系统的透析方式、保险类型和合并症的数据。我们使用多变量逻辑回归估计了该政策对家庭透析使用的影响，并比较了对医疗保险A/B部分受益人的影响与对其他类型保险患者的影响。到研究期结束时，终末期肾病前瞻性支付系统使家庭透析的使用增加了5.0%（95%置信区间[95%CI]，4.0%至6.0%）。医疗保险受益人中家庭透析的使用增加了5.8%（95%CI，4.3%至6.9%），其他形式医疗保险覆盖的患者中增加了4.1%（95%CI，2.3%至5.4%）。这两组之间的差异无统计学意义（1.8%；95%CI，-0.2%至3.8%）。相反，在这两个人群中，培训附加费用与家庭透析使用的增加无关，超出了政策的影响。终末期肾病前瞻性支付系统的捆绑支付，而非培训附加费用，与家庭透析的大幅增加相关，这对医疗保险和非医疗保险患者都是相同的。这些溢出效应表明医疗保险中的重大支付变化可以影响所有终末期肾病患者。
