Will Studies Of Patient "Noncompliance" Justify Cherry Picking?

By Peter Laird, MD

The for-profit dialysis industry is scrambling to put together new strategies on how to maximize their profits in the new CMS Medicare renal dialysis bundled payment system. This is the first time since the inception of the 1973 ESRD program that pay for performance has been part of the reimbursement structure. Even so, it will only put at risk up to 2% of total payments to any center in one year based on anemia management and urea reduction ratio (URR). With the onset of the QIP in only a couple more months, some in the industry are looking for excuses to avoid the penalties. A recent study illustrates the frustration that some are expressing about meeting even minimal quality indicators:

Patients who don't follow treatments hurt dialysis clinics' pay

Recently, Medicare implemented a pay for performance program for reimbursing dialysis clinics that provide care to kidney disease patients. One goal consists of achieving adequate dialysis dose (the amount of blood that is purified) in > 96% of patients in every clinic. Therefore, clinics that don't meet the 96% goal would get financially penalized.

Navdeep Tangri, MD (at Tufts Medical Center during the study and currently at the University of Manitoba in Winnipeg, Canada) and his colleagues looked to see if patient characteristics affect whether dialysis clinic achieve this goal. By analyzing electronic health records from 10,069 dialysis patients across 173 clinics and using advanced statistical methods, the researchers found that patient characteristics—particularly how well they followed their prescribed treatments—had a tremendous impact on a facility's achievement of the pay for performance measure. For example, patients who shortened or skipped dialysis treatments or gained weight between treatments played a major role in determining whether dialysis clinics fell short of reaching their goal.

The findings indicate that dialysis clinics that provide care to a greater proportion of patients who don't follow their prescribed treatments—which tend to cluster in low-income urban areas—would get unfairly penalized under the current payment system. "We believe that these penalties may lead to cherry picking against disadvantaged patients, and therefore widen disparities in care," said Dr. Tangri. The authors noted that alternatives to penalizing clinics that care for patients with complex medical and/or social problems are needed.

Unfortunately, cherry picking of the best dialysis patients with employer based health care plans is deeply engrained in dialysis practices already. No where else in medicine are the rules of patient abandonment pushed to the limits as that of American dialysis units that at times dismiss patients from their units with the only alternative these patients have is to seek treatment at the local emergency rooms.

It is quite easy to be labeled a non-compliant patient. When I traveled to see my parents a year after starting dialysis, the new unit on the first day came to me and bluntly stated, "you refused EPO" based on what was written in my transfer summary. The true story is that I didn't need any EPO with a Hb over 12.0 on iron supplements alone coupled with my prior history of cancer. Not only was EPO not indicated in my case, it was also contraindicated, yet I was labeled by my home unit as a patient who had "refused" EPO which implied an underlying noncompliance. Nothing could be further from the truth. I was instead a well informed patient exercising my right to choose my own treatment options. In many cases, patients who seek to maximize their own treatment choices are quickly labeled non-compliant and documentation to that effect occurs.

On the other hand, the usual in-center dialysis treatment is one of short treatment times and high ultrafiltration rates that cause severe vascular compartment fluid loss rapidly leading to early signs of circulatory collapse and shock with nausea, lightheadedness, dizziness, vomiting, severe cramping and at times hypotension leading to syncope. In many units, supplies are chronically limited and staff are severely overworked. Many patients end a dialysis treatment strapped to an ambulance gurney en-route to the nearest emergency room. Is it any wonder that many patients simply don't want to participate with every scheduled patient given the true torments that they suffer at the hands of those pledged to secure their health.

I am not surprised that the reaction to the QIP is to seek routes of escape from the loss of even 2% of pay for a poor performance instead of seeking to overcome these deficiencies. That was not the intent of the QIP which instead was instituted to improve quality and activate quality improvement processes in the dialysis units. If this article is any indication of the response of the for-profit dialysis industry, then cherry picking appears to be their response to these newly imposed minimal quality standards instead of dealing with these known problems. That would be a sad testimony of our dysfunctional American dialysis industry. Unfortunately, it is the most likely response that we will see.

http://www.hemodoc.com/2011/10/will-studies-of-patient-noncompliance-justify-cherry-picking.html