While the ESRD Seamless Care Organizations, Dialysis Patients Act and Renal Physicians Association Model all address integrated care, according to the published perspective of a nonprofit dialysis provider, the biggest differences are the optimization of patient care vs. provider financial return.
According to the authors, these differences could negatively impact the competition of small providers with larger ones. The authors said integrated care should strive to retain patient choice, not restrict provider access to the marketplace.
“Integrated care should treat patients with CKD as individuals with important current clinical needs, not just as people who may someday be treated by dialysis or kidney transplantation,” wrote Douglas S. Johnson, MD, vice-chairman of the Board of Directors for Dialysis Clinic Inc., a non-profit dialysis provider, and Klemens Meyer, MD, with the Division of Nephrology at Tufts Medical Center in Boston, Mass.
Each of the aforementioned programs financially incentivize providers, big and small, to immediately start patients on dialysis rather than delay or avoid it.
The Renal Physicians Associations Model gives incentives to providers for transplantations but, according to the authors, should increase those incentives, reflecting the lower cost due to transplantation as well as patient benefit.
The perspective claimed that advocates of the Dialysis Patients Act argue that the ESRD Seamless Care Organizations (ESCO) model is unappealing to smaller provider and physicians because it requires they assume risk. However, under the Dialysis Patients Act, providers must also become insurers, according to the authors, and without the capital smaller providers would not be able to compete. They claimed this aspect of the Dialysis Patients Act is a feature, not a bug.
“Two providers now treat [more than] 70% of dialysis patients in the United States; a model designed to improve care should not promote further consolidation,” Johnson and Meyer wrote. “The difference between ESCOs and plans established under the Dialysis Patients Act is that, under the latter, only the largest organizations would have the capital to act as insurers.”
According to the authors, in a 2003 to 2014 study of patients treated at a nonprofit dialysis provider vs. the two largest providers, mortality and hospitalization rates were lower at the nonprofit provider. In other analyses, researchers saw stronger cultures of safety at nonprofit dialysis facilities.
Additionally, the authors noted that by the Dialysis Patients Act, providers who also behave as insurers would see no requirement to meet Medicare Advantage Plan safeguards.
The ESCO program has granted shared earnings without compromising quality of care and continues to show promise for the improvement of care, according to the authors. They continued that ESCOs should be expanded to include stage 4 and 5 CKD, provide financial incentives for transplantation, as well as allow new ESCOs to form.
“The Dialysis Patients Act, as currently written, is a bad idea,” Johnson and Meyer wrote. “We hope that it will be revised to add Medicare Advantage safeguards; to limit program size; to allow open networks only; to make it possible for small providers to establish independent programs; to support improved care before CKD causes uremia; to replace the current incentive to initiate dialysis with incentives to delay dialysis and promote transplantation; and to improve advance care planning.”
The authors concluded, “Medicine is not a business.” – by Scott Buzby
Disclosures: Meyer reports that his employer receives funds from Dialysis Clinic Inc. that are used to support his salary. Johnson reports he is an employee of Dialysis Clinic Inc. and serves as vice chair of its board of directors.