By Bill Peckham
How is this Copernican system defined in terms of policies, metrics, and financial incentives?
From earth whether we believe we are at the center of the universe with the Sun and all else orbiting us ... or vise versa, it looks the same. To the casual observer there is no difference, either way the sun comes up in the east and sets in the west. However, there is an undeniable difference in mindset and if you are working to understand our solar system it is important to see the world's place as it is, this is equally true in the provision of dialysis. Planet dialysis is not at the center of the system, planet dialysis orbits the patient. The patient is the star.
To a casual observer walking into a dialysis unit, self-centered dialysis would be indistinguishable from patient-centered dialysis. Where the two systems distinguish themselves is in the metrics and financial incentives. Today’s patient-centered dialysis puts the provider at the center of the universe, unit-wide results are judged against unit-wide expected outcomes. The financial incentives are directed at the provider. The patient's role is to be the input and the output. The patient-centered dialysis unit takes in uremic inputs and turns out slightly less uremic outputs. The CEO of one large dialysis provider said his approach would be the same if he was taking in hamburger and turning out tacos.
DPDA (the PATIENT Act) S.2065/H.R.4143 is a logical progression of a ptolemaic-like provision of dialysis. DPDA does away with all pretense, the Act tasks the dialysis provider as:
... a central command point for patients to access the coordinated health care services.
DPDA imagines planet dialysis at the center of the system with a galaxy of stars swirling around in orbit. The strategy behind the legislation is that dialysis organizations large enough to participate, those with capital reserves sufficient under Sec.1866F (b)(3) of the Act, will use their size to save money. With DPDA total spending becomes a driving metric, the patient is a business input to be managed.
In contrast a Copernican-like dialysis system, self-centered dialysis, puts the patient Medicare beneficiary at the center (we are not Medicare's patients). The responsibility for achieving metrics are the beneficiary's and the financial incentive is directed at the beneficiary. To see yourself at the center of your care is to understand that no one, no matter how benevolent, will care as much about your well being as you can and should care about yourself. There is no better way to align financial incentives, optimal care and self interest than to reward Medicare beneficiaries for their individual outcomes.
Thus, a self-centered dialysis QIP would allow Medicare beneficiaries to withhold their Part B premiums if they achieved, as an individual, the QIP blood and process goals. Instead of the shared savings imagined under DPDA accruing to the dialysis provider, self-centered dialysis would accrue shared savings to the Medicare beneficiary, perhaps in the form of payments to their Social Security account. If total spending is to become the driving metric in the provision of dialysis, let Medicare beneficiaries act as the responsible party. The stars are not orbiting planet dialysis; a system based on the belief that they are is bound to end badly.