Center of Innovation for Health Services Research, Durham Veterans Affairs Health Care System, Durham, North Carolina.
Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.
Clin J Am Soc Nephrol. 2020 Nov 6;15(11):1631-1639. doi: 10.2215/CJN.02100220. Epub 2020 Sep 22.
Because of the limited capacity of its own dialysis facilities, the Department of Veterans Affairs (VA) Veterans Health Administration routinely outsources dialysis care to community providers. Prior to 2011-when the VA implemented a process of standardizing payments and establishing national contracts for community-based dialysis care-payments to community providers were largely unregulated. This study examined the association of changes in the Department of Veterans Affairs payment policy for community dialysis with temporal trends in VA spending and veterans' access to dialysis care and mortality.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: An interrupted time series design and VA, Medicare, and US Renal Data System data were used to identify veterans who received VA-financed dialysis in community-based dialysis facilities before (2006-2008), during (2009-2010), and after the enactment of VA policies to standardize dialysis payments (2011-2016). We used multivariable, differential trend/intercept shift regression models to examine trends in average reimbursement for community-based dialysis, access to quality care (veterans' distance to community dialysis, number of community dialysis providers, and dialysis facility quality indicators), and 1-year mortality over this time period.
Before payment reform, the unadjusted average per-treatment reimbursement for non-VA dialysis care varied widely ($47-$1575). After payment reform, there was a 44% reduction ($44-$250) in the adjusted price per dialysis session (<0.001) and less variation in payments for dialysis ($73-$663). Over the same time period, there was an increase in the number of community dialysis facilities contracting with VA to deliver care to veterans with ESKD from 19 to 37 facilities (per VA hospital), and there were no changes in either the quality of community dialysis facilities or crude 1-year mortality rate of veterans (12% versus 11%).
VA policies to standardize payment and establish national dialysis contracts increased the value of VA-financed community dialysis care by reducing reimbursement without compromising access to care or survival.
由于自身透析设施容量有限，美国退伍军人事务部（VA）退伍军人健康管理局通常将透析护理外包给社区提供商。在 2011 年之前——VA 实施了标准化支付和建立全国社区透析护理合同的过程之前——对社区提供商的支付基本上是不受监管的。本研究考察了 VA 对社区透析支付政策的变化与 VA 支出和退伍军人获得透析护理和死亡率的时间趋势之间的关联。
设计、设置、参与者和测量方法：使用中断时间序列设计和 VA、医疗保险和美国肾脏数据系统数据，确定在 VA 政策颁布之前（2006-2008 年）、期间（2009-2010 年）和之后在社区透析设施中接受 VA 资助透析的退伍军人，以标准化透析支付（2011-2016 年）。我们使用多变量、差异趋势/截距转移回归模型来检查在此期间，社区透析的平均报销、获得优质护理的情况（退伍军人距离社区透析、社区透析提供者数量和透析设施质量指标）以及 1 年死亡率的趋势。
在支付改革之前，非 VA 透析护理的未经调整的每次治疗平均报销费用差异很大（$47-$1575）。支付改革后，每次透析治疗的调整后价格降低了 44%（$44-$250）（<0.001），透析费用的变化也减少了（$73-$663）。在同一时期，与 VA 签订合同向患有 ESRD 的退伍军人提供护理的社区透析设施数量从 19 家增加到 37 家（每家 VA 医院），社区透析设施的质量或退伍军人的粗 1 年死亡率均无变化（12% 对 11%）。
VA 标准化支付和建立全国透析合同的政策通过降低报销而不影响获得护理或生存的机会，提高了 VA 资助的社区透析护理的价值。
