Offering an EOD schedule is the best response to patients skipping treatments

By Bill Peckham

At the risk of becoming The Bruce Dikinson of the dialysis industry, when I read the JASN abstract that connects skipping dialysis with URRs below 65%, and thus a 1% payment withhold under the QIP, I think the only prescription is more cowbell! dialysis! Offering Every Other Day (EOD) schedules is the best response to control the cost of skipping.

The JASN paper only addresses the costs associated with being subject to a 1% withhold under the QIP, this understates the cost to the unit of skipping.

Think of a person who comes every treatment, who dialyzes 156 times a year, who we'll call G ... compared to someone who tends to skip twice a month and at the end of the year has dialyzed 130 times, who we'll call D.

First, one reason a person may skip regularly is that they don't feel very well when they do dialyze three times a week; if you're going to feel unwell if you do or you do not go to dialysis, you'll be more likely to not go. EOD schedules, when followed, would increase the person's chance to feel well, thus their ability and willingness to accommodate regular dialysis. But we're talking money, skipping and costs.

On the cost front, consider G's financial impact. Each dialysis payment under the expanded bundle is made up of fractional payments. Lab tests are in the bundle; each one of G's 156 reimbursements include some amount intended to cover lab tests. If G dialyzes 13 times in the month it means that the unit received 13 fractional payments intended to cover the cost of labs.

In addition with each payment the center received fractional payments to cover other monthly services and fractional payments for services that are delivered quarterly or yearly. All sorts of services required by the Conditions for Coverage are paid for a little at a time out of each individual, treatment, reimbursement e.g. the cost of care planning, iron, social worker support, PTH tests, Hepatitis tests, nutritionist support are all paid for a little at a time, by each treatment even though they don't necessarily happen each treatment.

Now consider D's financial impact. Labs still need to be done each month but at the end of the month there are only 11 fractional payments available to pay the cost of running the tests. D, just through skipping, generates 16% less revenue to pay for services delivered at frequencies less than each treatment.

The biggest financial effect may be D's EPO profile before and after skipping. In general let's assume D will need the same yearly dose of EPO whether dialyzing 156 times a year or 130, D will need 624,000 units of EPO (likely D would need a higher yearly dose due to skipping). If D runs 156 times the EPO dose will be 4,000 units per treatment. If D runs 130 times the EPO dose will need to be 4,800 units per treatment. D's skipping makes each treatment less lucrative, over and above any QIP withhold.

EOD schedules fix the financial side of this problem. Skipping in and of itself is a clinical problem, and as the JASN authors note there are as many reasons for skipping as the mind can imagine. But skipping shouldn't mean not having access to dialysis and units shouldn't be trapped into a needless financial drain. I don't think D is thinking: I only need to dialyze 11 times this month, more likely, about twice a month, D has a sense that: I need a break.

With an EOD schedule D would receive the 13/month medical minimum number of treatments - enough dialysis to avoid expensive hospitalizations and keep URRs above 65%; the unit would have received the number of payments anticipated by the bundle to pay for formerly separately billable services; and D would have had two breaks during the monthly grind. Win. Win. Win.

D should be given an EOD schedule and expected to call the unit as soon as the intention to skip is known.

Every Other Day (EOD) incenter dialysis schedules can be done (Part I); EOD schedules would improve clinical outcomes and support patient choice (Part II); EOD schedules are implicitly supported by MAC/FIs (Part III); EOD schedules would improve the clinic's finances and may lower overall Medicare costs per person, per year (Part IV); EOD schedules would increase the clinic's value (Part V). And, EOD schedules are a sensible clinical and financial response to patients who routinely skip treatments.

Comments

[Dori Schatell]

Unfortunately, what I hear is already happening is that the nephrologist will discharge "D" from the center rather than risk the loss of center revenue. The center can then use "No Physician Care" to route around Medicare's rule about NOT allowing involuntary discharge due to "noncompliance". Problem solved! For the center--not for "D" who will have a tough time finding a new center to take him...

[Bill Peckham]

In addition to being unethical, that's bad business. I'm realizing that most medical staff have a shallow understanding of dialysis finance.

[Peter Laird, MD]

Unfortunately, they have the law on their side. Dialysis treatment is considered for a chronic condition and therefore is not subject to the same laws as ERs and doctors offices where a patient MUST be treated if in immediate danger. The courts have already ruled that ESRD is a chronic condition not subject to those laws.

In addition, dialysis units are legally allowed to dismiss a patient for "noncompliance." All of those patients that fail to show up for EVERY single session or leave early will have those events documented. If these patients cannot meet the 65% URR or the anemia measures, they will be at severe risk of dismissal. Unless the dialysis population itself stands up and starts calling the local media to publicize what will surely happen, there will be no recourse for these patients except the local ER which will not offer 3 times a week dialysis, but instead only when they are acidotic or hyperkalemic.

The industry will play this game until CMS discontinues these minimal QIP markers. This is an industry out of control and completely profit motivated.

[Bill Peckham]

There has been an embrace of business ethics in place of medical ethics. My point is that if you're going to embrace the ethics of the businessman you should also embrace the math of the businessman.

Right now, at this moment in time, financial incentives are aligned with giving care that is superior to the care that exists, to the care that Dori has heard about and that the JASN paper implies.

I see a troubling dissonance, in an industry that is will to embrace the ethics of business but not its math.

[Peter Laird, MD]

Bill, you are absolutely correct that the business of dialysis is in dissonance in many ways. Under the bundle, EOD should be a plus as you have outlined. In addition, home hemodialysis options should entail higher profits from a lower overhead and reduced staffing needs. Yet, despite the financial benefits many other nations enjoy with home dialysis patients, America is only slowly increasing home hemodialysis numbers. Sadly, the over all reduction in program costs by improved care and reduced hospitalization is completely ignored at the CMS level which could intervene, yet they don't.

[Dori Schatell]

And, we're back to the Medicare Part A/Part B wall. We need to tear down the wall to align the incentives to keep people healthy! Unfortunately, Congress, in its great medical wisdom, may well be dooming some people to untimely deaths by insisting on a "stick" vs. a "carrot" approach to Pay for Performance.

Peter, noncompliance is specifically NOT a reason for clinics to involuntarily discharge someone. But, it doesn't matter when the MD can do it for them...

[Bill Peckham]

But Dori, the whole point of this series of posts is that we don't have to do anything except offer more dialysis. Everything is in place except the will.

It would be interesting to see, would EOD schedules save $5,000/year that it costs but it doesn't need to happen for there to be EOD schedules.

Nothing else has to happen, it is there for the doing.

[Peter Laird, MD]

Dori, according to some nephrologists, they are including people who refuse to remove catheters as a reason to consider dismissal.

"Some examples of behavior that might be labeled as non-compliant or disruptive but not necessarily directly harmful to other patients include missing multiple dialysis sessions requiring subsequent emergent dialysis treatment, failing to take phosphorous binders and as a result having extremely elevated phosphorous levels, refusing permanent access when such access would be possible and subsequently developing catheter related infections, . .

More subtly, if a patient winds up having to be admitted repeatedly to a hospital for complications deemed secondary to their noncompliance, there may be pressure on medical directors not to accept the patient back into their dialysis units. I think that these are particular examples of the general problems raised by “cherry picking” dialysis patients."

http://www.thekidneydoctor.org/2011/10/dialysis-unplugged-patient-physician.html?utm_source=BP_recent

[Joe Wear]

I would say from my experience of watching the skippers at my unit that this won't improve their compliance. Many of these same folks who skip also routinely cut their treatments short. Dropping 30-60 minutes off of half your runs in a month is as bad or worse than outright skipping. Frankly I think that many of our fellow patients have deeper issues that need to be addressed, after all being non compliant got a lot of folks in that chair in the first place.

[Bill Peckham]

I hear you Joe but if people are routinely shortening their runs I say more cowbell dialysis, greater frequency, is the answer.

In general I believe we should strive to bend the treatment to fit the individual rather than bending individuals to fit the treatment.

[roberta mikles]

Dismissals are often, if not more, at the desire and for the benefit of staff e.g. not wanting to take care of a patient who speaks up for safe care, or one who 'rocks the boat' by calling attention to unsafe or incorrect practices, or even if a patient is not liked. Patients are labeled and if one staff does not like a patient, for whatever reason, the rest of the herd follow suit, often regardless of how they truly feel... just to be part of the cohesiveness of the unit -- the unspoken word 'stick together no matter what'. How many times did a tech tell me they would not report something they observed by a coworker that was wrong.
And, who ever said that the QIP would give more information regarding the quality of care.. geeshhh... unbelievable. If you go to the DFC site you see the reports that have to be posted in the units. These are just a repeat of the old existing DFC charts e.g. anemia management, etc..So what if a patient has a good hemoglobin if they are admitted to the hospital due to the wrong K+ bath given, or a septicemia.?
Continues to amaze me the care that some patients are receiving in some units and CMS, as well as our legislators could care less as evidenced by all that we see ---
opinions of ---
Whatever happened to the EOD petition?????
Roberta Mikles BA RN
Dialysis Patient Safety Advocate
www.qualitysafepatientcare.com
Roberta

[roberta mikles]

P.S.
How many times did I see staff, in many units, make a patient wait for their chair due to valid and invalid reasons. Sometimes, making a patient late for an appointment, or even a part time job. Then, at times, cutting that next patient's treatment time short. If a patient is late, due to a very valid reason, often their time was cut short.. I watched, in our unit specifically, staff cut times short just because they wanted to go home early
Roberta Mikles BA RN
Dialysis Patient Safety Advocate
www.qualitysafepatientcare.com

[somerville]

If you impose on patients a form of 'treatment' which amounts to a torture which destroys life as the coherent, autonomous, realization of human purpose it should be, then it becomes difficult to distinguish 'non-compliance' from genuine attempts by the patient to preserve his life as a meaningful social phenonemon. Refusing to take a pill a day out of pure stubbornness is the paradigmatic case of non-compliance, but trying to live a bit of real life against the intrusions of dialysis programs designed more for the convenience of the medical staff and the profit of the dialysis unit owners is not something which should be punished. The real 'non-compliance' here is the failure of medical science to develop a renal replacement treatment which is compliant with the demands of social life, not the patient's rational protest against this abusive and inadequate treatment.

[roberta mikles]

Perhaps, staff and physicians should be trained to determine and intervene as to why patients present with what they call non compliance. I always have to laugh at the ironic situation -- if a patient is non compliant they are often dismissed, at the drop of a hat. The staff expect patients to be compliant, often with no reasons for such. However, when a patient, or loved one, has expectations for staff and physician to be compliant with Conditions and unit policies and procedures, it is a different story. A patient is often retaliated against, etc. when he/she speaks out when there is staff non compliance. Interesting, isn't it. A true double standard of sorts. The more I hear the more I realize the complete misunderstanding of what it means (for staff/physicians)to treat a patient with a life-sustaining mechanism. Perhaps as my father always said '' they need to walk in my shoes and sit in my dialysis chair to understand what I go through".

wHAT EVER HAPPENED TO 'DO NO HARM'

Roberta Mikles BA RN
Director, Advocates4QualitySafePatientCare
www.qualitysafepatientcare.com