Home dialysis is becoming less popular, thanks to the 2004 Medicare transition to tiered fee-for-service physician reimbursement.
Dialysis is a common treatment for individuals who find themselves in need of a kidney transplant, but are unable to receive one due to a shortage of kidneys. Those on dialysis have multiple treatment options. In-center hemodialysis finds patients going into a dialysis center multiple times a week for treatment. Home based treatment--including peritoneal dialysis and home hemodialysis--is a flexible alternative.
In a paper titled “Effects of Physician Payment Reform on Provision of Home Dialysis,” patients with traditional Medicare who were affected by the policy change were compared to those who had Medicare Advantage and were thus unaffected by that change.
The study took into account data from patients starting dialysis three years before the reform and three years after it. The study also took a look at if the policy had more of an influence on dialysis method assignment in areas where the cost of traveling for dialysis was lower.
The paper noted that among those with traditional Medicare there was a 0.7% reduction in the absolute probability of home dialysis use after the payment reform change, compared to those with Medicare Advantage.
When comparing patients at larger dialysis centers with those at smaller centers, the study found that there was a 0.9% reduction in home dialysis for those at the larger centers. Payment reform made in-center treatment more lucrative for physicians at larger dialysis centers.
"We found that national physician payment reform enacted by Centers for Medicare and Medicaid Services in 2004 in an effort to encourage more frequent face-to-face dialysis visits and improve the quality of care resulted in an unintended consequence of relatively fewer patients choosing home dialysis," wrote the authors, who hailed from Rice University’s Baker Institute for Public Policy, Stanford University and Baylor College of Medicine.
This study comes on the heels of a 2015 report from the U.S. Government Accountability Office (GAO). The House of Representatives Committee on Ways and Means’ Subcommittee on Health asked for information on barriers to home dialysis use. GAO found that the current payment policy offered incentives that could act as a barrier to home dialysis use. This new study now offers more detailed evidence to support that claim.
"The tiered fee-for-service payment system enacted in 2004 continues to govern physician reimbursement for in-center hemodialysis care and, consequently, may continue to discourage home dialysis use in certain patient populations,” the study authors wrote. “These findings highlight both an area of policy failure and the importance of considering unintended consequences of future efforts to reform physician payment."
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