A recent article in The Wall Street Journal describes “The Simple Idea That Is Transforming Health Care”-focusing medical providers on patient quality of life (QOL) and integrated and holistic care.  The article provides example after example of how a focus on patient-centric approaches to care, if applied appropriately can be the driver of the metrics that are more typically viewed by health plans and regulators, such as mortality and hospitalization. While the concept that optimizing QOL is an important goal in life and in medical care is intuitive, does apply well to patients with chronic illnesses, and if so, are we in nephrology sufficiently engaged in this effort?

The segment of the American public with chronic illness is growing as the population ages and as obesity, diabetes and hypertension all increase in prevalence. We have seen the results, of course, in the continuing growth of incident ESRD patients, two-thirds of whom have diabetes and or hypertension as a cause or complication of kidney disease. We as a renal community have continued to pursue the more traditional metrics of outcomes success -and not even very rigorously since we are tracking and being held accountable primarily for intermediate or surrogate outcomes such as dialysis adequacy, anemia, and so on. Although standardized mortality and hospitalization ratios (SMR and SHR) are also available, the value and accuracy of these is open to debate because the key to the standardization is the “expected” mortality/hospitalization rate and the elements that are considered in that calculation. There have been no publications independently verifying the accuracy of SMR or SHR in this population.

For many years we have been focusing on patient-centric care at DaVita, including through our disease management group VillageHealth®. An integral component of the VillageHealth program is the patient activation measure (PAM) which gauges the knowledge, skills and confidence essential to managing one’s own health and healthcare. The PAM assessment segments patients into one of four progressively higher activation levels. Each level addresses a broad array of self-care behaviors and offers insight into the characteristics that drive health behaviors.

Activated patients are fully engaged as participants in their care, are more adherent with medications and other aspects of care, and have lower hospitalization rates, better survival, and higher QOL.

We have recently conducted extensive surveys and focus groups with patients to better understand what is important to them when they are getting ESRD care. I expected that great clinical outcomes like fewer catheters and outstanding phosphorus levels would be near the top of the list. However,  none of the clinical outcomes came close to the desire of patients to be treated as human beings -for caregivers to truly treat them holistically, to care about them as people and about their families to understand what is important to them and to help them achieve their life goals.

The challenge of responding to these needs is considerable. The current standardized instruments we have for assessing QOL, including the KDQOL, are imperfect and as shown recently by Tracy Mayne, an international authority in this area and a member of DaVita Clinical Research® (DCR®). KDQOL cannot be validated as truly predictive of QOL with current ESRD patients. While the search for a reliable, reproducible, valid instrument to measure QOL goes on, we all need to commit to the importance of this area.

Nephrologists, as leaders of the healthcare team for our patients, need to be sensitive to the integrated and holistic needs of patients and be role models for other members of the team. All caregivers need to believe that hitting QIP targets or other quality metrics is important, but caring about the patient as a person is at least as, if not more, important. We should all encourage our patients to take advantage of the full range of tools to increase their empowerment.

We have developed a teaching program for CKD patients (KidneySmart™), have a website for ESRD patients and have dedicated social workers who focus every day on helping patients have their hopes and dreams known and fulfilled to the extent possible. But these tools are not enough unless we are all willing to make a paradigm shift in the way we think about what is really important in the lives of these vulnerable and fragile patients.

Some time ago the clinical leadership at DaVita® began a journey to understand and then address how we can truly make a difference in our patients’ lives. It all starts with a vision, and I now state this vision under my signature on every email I send, just to remind me:   “Advancing Integrated and Holistic Care to Realize the Vision of Our Village”.

As Hippocrates said over 2500 years ago:

“It is more important to know what sort of person has a disease than to know what sort of disease a person has.”

Striving to bring quality to life,
Allen R. Nissenson, MD
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I recently had a chance to round on some in-center dialysis patients at my facility at UCLA. It was incredibly heartwarming to see so many of my former patients still doing so well. It was a real homecoming for me. As I made rounds with Fellows and the entire interdisciplinary team, I started to reflect on what it meant to be a leader in a complex healthcare-delivery setting. There is no setting in medicine that better reflects the need for leadership than care in the dialysis facility. So what are the components of a true leader—things we never learned in medical school, but that are so critically important for our patients as we serve as leaders in dialysis facilities? Each person needs to determine what he or she truly believes struck a chord. Our leadership is based on our belief in truth, grace, growth and freedom. Beliefs determine behavior that defines performance as a leader.

Truth involves standards, honesty, discipline, integrity and clear expectations; grace is not a religious reference but includes showing others that you are on their side, that you have empathy, compassion and understanding; growth is characterized by demanding feedback, being self-aware, understanding others, and having humility and discipline; freedom means being encouraging and secure, and forgiving and empowering others—it leads to serving others, and true power comes from giving power to others.

You need to define what you believe as a leader, but these are right on for me. To be true to yourself, evaluate your leadership: 1) The gap: how far are you from where you want to be?; 2) The fit: how do I fit my role?; 3) Feedback: what do others say?; 4) Parallel context: how are others in similar roles doing?

Sound like a business-school exercise? Sound irrelevant to the day-to-day grind of a nephrologist/Medical Director? Think again. Leadership is demanded of nephrologists, and such leaders will not only have great dialysis facilities with incredible patient outcomes, but will also have successful practices and fulfilling lives.

One of the great things about DaVita is the incorporation of core values into everything that is done in the organization. As I made rounds I had a true epiphany—the way I conduct myself is exactly the articulation of the DaVita core values! I first and foremost am committed to enable high quality of care by serving my patients and delivering service excellence. To be a true leader and be trusted by colleagues and patients and their families, this service excellence must be delivered with the greatest integrity; we say what we believe and we do what we say. Delivering credible, excellent care cannot be done by one individual, but requires a team working together with a common vision to improve the lives of patients with kidney disease. We must, of course, never be satisfied with where we are, but rather must always strive for continuous improvement. We also must be humble and understand that none of us is always right, and we must be willing to ensure that accountability for one’s own actions is something we insist upon from our colleagues and our patients. If we can drive excellent service, in a transparent way with full integrity, working with a team, continuously improving and holding ourselves accountable, then we can experience true fulfillment while still having fun in the process. Is this an achievable vision? I would submit yes—I am living it!

So, stepping up and being a leader, while always anchored by fundamental core values, is for me the way to do the best I can for my patients and to live the most fulfilling life possible. Are you a leader? What are your core values? Take some time to answer those questions. It might just be the most valuable time you have spent in your hectic life as a nephrologist.

Remember what the great management guru Peter Drucker said:

“The leaders who work most effectively, it seems to me, never say ‘I.’ And that’s not because they have trained themselves not to say ‘I.’ They don’t think ‘I.’ They think ‘we’; they think ‘team.’ They understand their job to be to make the team function. They accept responsibility and don’t sidestep it, but ‘we’ gets the credit…. This is what creates trust, what enables you to get the task done.”

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

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Allen R. Nissenson, MD, FACP, Chief Medical Officer, DaVita
Dr. Nissenson explains Accountable Care Organizations (ACOs) in more detail and the clinical care opportunities for the kidney community.

For more information on the future of Accountable Care Organizations visit www.AccountableKidneyCare.com

In this short video, Allen R. Nissenson, MD, FACP, Chief Medical Officer, DaVita, shares why taking the proper care of the kidney population is so important for Integrated Care Systems or ACOs.

Disclaimer: The views expressed in this presentation are the views of the speaker and do not necessarily reflect the views of DaVita, Inc. DaVita does not guarantee the accuracy of the data included in this presentation.

In 1972, during the term of President Richard Nixon, the House of Representatives was working on a revision of the 1965 Medicare and Medicaid programs. The work of the House was nearly completed when an amendment was proposed and passed, Section 299I of Public Law 92-603, titled: “Chronic Renal Disease Considered to Constitute Disability.” The amendment added the following short phrase to the list of eligibility criteria for Medicare entitlement: “[an individual who] is medically determined to have chronic renal disease and who requires hemodialysis or renal transplantation for such disease.” The bill was passed on October 30, 1972, and the program was enacted on July 1, 1973.

So, 2012 is the 40th anniversary of that historic amendment, which ensured access to kidney care for thousands of people. Although this is not the precise birthday, I was compelled to write this blog because of a front-page article in the Sunday New York Times on Feb. 18. The headline read: “60 Lives, 30 Kidneys, All Linked: Intricate Balancing Act Produces a Record Chain of Transplants.” In the article, the domino chain–transplantation approach is explained. It is truly remarkable how many lives have been changed by this approach, which is increasingly necessary because of the massive shortage of available donor organs.

What caught my eye in the article, however, were some characterizations of dialysis: “Since receiving a diagnosis of diabetes-related renal disease in his mid-40s, he had endured the burning and bloating and dismal tedium of dialysis for nearly a year”; “Only half of dialysis patients survive more than three years”; “Many of the 400,000 Americans who are tethered [italics mine] to dialysis”; “Dialysis … saps the productivity of caregivers as well as of patients.” OK, anyone who has cared for dialysis patients knows that being on dialysis is difficult, and none of us is satisfied with the clinical outcomes or quality of life of our patients, but how often do we or our patients reflect on how far we have come, not just on how long and difficult the road ahead remains?

Thomas Graham is generally regarded as the first pioneer of diffusion-based dialysis. Working as a chemist in Scotland in the 19th century, Graham separated substances using a semipermeable membrane. Over the next century, many innovators contributed to the development of modern dialysis, including John Abel, Leonard Rowntree and Benjamin Turner; Georg Haas; Willem Kolff; and of course Belding Scribner. It was the incredible work of Scribner’s Seattle team that made chronic dialysis possible and a reality.

Here we are in the early 21st century and have the shoulders of such giants on which to stand. The promise of continuously operating, wearable dialysis devices is no longer a dream but rapidly becoming a reality. Recent research suggests that more frequent and longer treatments offer the hope of enhanced survival, fewer hospitalizations and higher quality of life. Extensive research is underway on in vitro growth of functioning kidney tissue and on reaching the Holy Grail of transplantation — true tolerance. While we wait for such breakthroughs, we would do well as nephrologists to read the inspirational book written by Lori Hartwell, someone who has had a life filled with illness, dialysis and transplantation. Lori’s book is “Chronically Happy: Joyful Living in Spite of Chronic Illness.”

So, happy birthday, Medicare ESRD program. Had you never been born, countless millions would have died of kidney failure. The current dominant treatment, dialysis, is not perfect, but it is continually improving. Those of us entrusted with caring for this fragile group of patients must always remember that we are also treating families and caregivers. The responsibility is enormous, but by working together — doctors, nurses, social workers, dietitians, technicians, families, caregivers and researchers — we can continue to do what is the true calling of medicine: provide holistic, patient-centric care that considers all of the unique attributes of each patient and family and strives to enable all patients to live the life to which they aspire. After all, who won the race, the tortoise or the hare?

Kahlil Gibran provides poignant advice for all of us: “Advance, and never halt, for advancing is perfection. Advance and do not fear the thorns in the path, for they draw only corrupt blood.”

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

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My wife is a maniacal exerciser. Three days a week at the gym, weights and cardio; two days a week, Pilates; Saturday, walk on the beach with a girlfriend; Sunday, walk on the beach with me. Although she comes from a family of women with osteoporosis, she has incredible bone density.

Two weeks ago, we were in Santa Barbara visiting our niece, her husband — a postdoc at University of California–Santa Barbara — and their beautiful five-month old daughter. After a wonderful visit, we took off for a relaxing lunch and stroll in Carpenteria, a few miles south of Santa Barbara on the way home to Los Angeles. We were walking around the main drag when my wife turned to point to a cute shop, tripped, and hit the ground. Her foot immediately began to swell, so we got some ice for the one-hour drive home.

Over the weekend, we treated the foot with ice, heat and liberal painkillers, but by Sunday night we knew that we would need to see an orthopedist for an examination and x-rays. That is when it began to get really painful.

On Monday morning, I contacted the chief of orthopedics at a nearby hospital who had his assistant squeeze my wife in to see someone at noon that day. The administrative assistant who made the arrangements couldn’t have been nicer, and we felt like we were on our way to a resolution. We drove to the new state-of-the-art facility. It was a blustery day, and we had been told that we should drive up to valet parking so we could get a wheelchair to take my wife to the appointment. When we pulled up, the valet said, “Sorry, the garage is full.” I insisted that I needed to help my wife to the appointment; after consulting his colleagues, the valet came back with a ticket and took the car.

We walked to the bank of patient elevators, about a block inside the building, rode to the second floor and arrived to find out they had no record of the appointment. I called the administrative assistant who had made the arrangements, and she got that straightened out: “computer malfunction.” Next was the foot x-ray, with the patient having to navigate two large, heavy doors while holding a “patient notification pager” to get from the waiting room to x-ray. We saw a senior orthopedist, who diagnosed a Lisfranc fracture after the examination and review of the films. He thought an MRI should be done to better see the tendons and determine if a cast or surgery would be best. He wrote the order but said we would get a call in a day or two after the authorization was obtained.

By Wednesday, we hadn’t heard from the office and called — we were told they had the request but only one person in the office was authorized to interact with insurance companies, and she was out. Needless to say, after two additional days of pain and essentially no treatment, my wife was outraged. The office said they would see what they could do and would call us back. We called again on Thursday, and they said that the “insurance person” was still out; the one on the phone said it was not her job, but she would see if she could help and would return our call. When we called Friday morning, after not hearing from anyone on Thursday, we were agitated but glad to hear that the MRI had been authorized. We were instructed to call radiology for an appointment.

When we called, radiology said the earliest appointment was for the following Monday. We were incensed — a painful, though admittedly not life-threatening injury, and another several days before the needed test so that the correct treatment could be started. I again called the chief of orthopedics, and the administrative assistant called back in five minutes to say we could get the MRI at noon that day.

We were grateful, and my wife had a friend take her to the test. After it was completed, she asked the technician to please have the radiologist call the orthopedist with the results as soon as they were ready. He stated that the test was not marked “stat” and would be read the following Monday. When my wife went up to the desk to ask the radiology administrative assistant how to get this expedited, the assistant was sitting at the desk, eating lunch, and said, “There is nothing that can be done. It’s not marked stat, and only the ordering doctor can change that.” A final call to the chief of orthopedics, the MRI was read, and it showed not one but two fractures and the possible need for surgery.

No one could make up a story such as this, but it is all too common in our current healthcare system. None of the individuals involved in my wife’s care was hostile, rude or uncaring. They were all working within a system, however, that does not place value on being patient-centric. Like most of our care delivery system, perhaps with “elite” private and academic health centers the poster-children, it is more about “them” than it is about “us” when we are patients. Building beautiful new facilities and having the latest technology has little value when the system forgets why it exists — to provide compassionate, timely, high-quality care for individuals who are in pain, frightened and at the mercy of the system.

By the way, the fact that I was able to “pull strings” to accomplish even what was eventually done is not something of which I am proud. Like any husband, I was willing to do all that I could to make sure my wife was cared for in the best way possible. I am no different from any other husband, wife, son or daughter who wants only the best for their loved one. No one deserves anything less.

We should always remember that as physicians and healthcare workers, we are here to serve patients. As the founder of modern nursing, Florence Nightingale, said more than a century and a half ago: “Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion.”

Apollo 13 returned from moon orbit safely, and I hope we have the wisdom, foresight and ability to work together in teams to rescue our ailing healthcare delivery system.

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

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We have to admit — we are coming late to the party! The concept of a culture of safety began outside of healthcare in organizations that self-characterized as “high reliability,” where highly complex and often hazardous activities are a daily reality. Such organizations live and breathe safety from the senior executives to the frontline workers. The Agency for Healthcare Research and Quality (AHRQ) suggests that the following are key features of a successful culture of safety:1

• Acknowledgment of the high-risk nature of an organization’s activities and the determination to achieve consistently safe operations
• A blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment
• Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
• Organizational commitment of resources to address safety concerns

There are national efforts ongoing outside of AHRQ to address safety in healthcare, most notably the National Patient Safety Foundation (NPSF).2 This independent, nonprofit organization was established in 1997 and continues to provide programs to assist organizations in focusing on safety in healthcare. In 2006, a survey was conducted, led by the Renal Physicians Association (RPA), to get insights from patients and professionals on the state of patient safety knowledge and programs in ESRD/dialysis. This effort culminated in an ongoing website, Keeping Kidney Patients Safe, which is a fantastic resource in this area.3

Through the survey mentioned above, key areas of focus were identified, including hand hygiene, patient falls, incorrect dialyzer or solution, medication omissions or errors, non-adherence to procedures and venous needle dislodgement. Clearly, these are important issues of patient safety, and there are likely others that need attention as well. Missing from this list, however, are provider safety issues such as needle punctures. With the shrinking workforce in dialysis, keeping our colleagues in the dialysis facility safe is also an important imperative.

So, how do we implement the culture of safety in our facilities? By making a commitment as nephrologists and medical directors to make this a core part of how we function. The American Association of Kidney Patients (AAKP) has tried to get the patients involved in the effort with their national program, 5 Steps to Safer Health Care, described by Dr. Alan Kliger:4

• Speak up if you have questions or concerns
• Keep a list of all of your medications
• Make sure you get the results of any test or procedures
• Talk with your doctor and healthcare team about your options
• Make sure you understand what will happen if you need surgery

We need to make a commitment as we enter 2012: Establishing a culture of safety in our facilities will be a great gift for our patients and our staff, and we will make it happen! To do this successfully will require reassessment of the systems of care we currently have and a willingness to make the necessary changes.

As recently stated by Dr. Paul Batalden (and possibly attributable to W. Edwards Deming and/or Donald Berwick) of Dartmouth Medical School and the Institute for Healthcare Improvement (IHI):

“Every system is perfectly designed to get the results it gets.”

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

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References:

1.    http://psnet.ahrq.gov
2.    http://www.npsf.org
3.    http://www.kidneypatientsafety.org
4.    http://www.aakp.org

This is the time of year to reflect on the past 12 months, to be introspective and honestly assess where we have come and where we are going. As the themes of my blogs over the year have emphasized, patients with kidney disease are among the sickest of the sick, yet are embedded in a system of care that is largely dysfunctional. Uncoordinated care, inadequate focus on care transitions, lack of identification and management of co-morbid conditions, and too little preventive care all remain problems that must be overcome if we are to truly improve survival and quality of life for our patients.

Having said this, however, 2011 also showed us that there is clearly a growing momentum to do things differently, to restructure the way we think about and deliver care, and patients benefit. The one renal community initiative – PEAK, a program to lower incident patient mortality by 20% by the end of 2012 – is on track. The results of the CMS Global Capitation Demonstration Project are in and overall, with an intense focus on care coordination, survival improved, hospitalizations decreased and total costs of care were lower than in a matched group of Medicare fee-for-service population. Both DaVita and FMC identified the key drivers of poor outcomes and created customized programs including provision of nutritional supplements, use of biometric devices to control fluid overload, dramatic success with influenza and pneumococcal vaccination, and medication management therapy, among many others. These programs had one important characteristic in common – they were patient-centric, engaging patients in their own care and being sensitive to what each patient needed and wanted. Outside of the Demonstration, 2011 also saw a significant growth in home dialysis, particularly peritoneal dialysis, again demonstrating a sensitivity to patient needs and desires.

So why am I optimistic about 2012?  We now have a large number of approaches to improving outcomes that we know can work and are implementable. In addition, we are continuing discussions with the Center for Medicare and Medicaid Innovation (CMMI) and it looks more and more likely that a large-scale pilot program of integrated care management/care coordination will begin in the New Year. Finally, in mid-2011, a group of Chief Medical Officers from throughout the dialysis industry met together for the first time to discuss ways of substantially moving the quality needle for ESRD patients. This group is working closely with the KCP and KCC, ensuring alignment between business leaders and clinical leaders in the industry, along with policy makers. We have not seen this level of collaboration before and I am confident that 2012 will be just the beginning of new progress to improve the lives of patients with kidney disease. By working together, along with our patients, we can make this happen.

We would all do well to remember the words of Steve Jobs and try to live them as we start the new year:
“Everyone here has the sense that right now is one of those moments when we are influencing the future.”

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

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A recent editorial in the Clinical Journal of the American Society of Nephrology discusses the imperatives in the training of the future generation of nephrologists (1). In this insightful presentation Kohan notes five of the key forces that are driving what he calls a “perfect storm” in our discipline. The forces include increasing clinical workload, diminished interest in nephrology as a career choice, the changing nature of nephrology care, increased requirements for nephrology training programs from accreditation bodies and decreased funding for nephrology trainees and research. Mentioned as well is the excellent study by Berns published in 2010 demonstrating the dissatisfaction nephrologists had with the real-world preparation they received during their fellowship training (2).

Nearly seven years ago, we published a Special Article in Seminars in Dialysis following a preceptorship we organized for second-year nephrology fellows (3). This multi-day program, carried out by senior leaders in nephrology was attended by nearly 70 fellows, many from some of the most acclaimed nephrology training programs in the United States. As part of the experience we surveyed the participants to better understand the training programs from which they came. We were astonished by the responses, including:  50 percent of programs offered fewer than three months of experience in OP hemodialysis; 25 percent of programs offered no exposure to chronic peritoneal dialysis; 50 percent of programs offered fewer than three months of inpatient dialysis; and two-thirds of programs offered fewer than three months of transplantation. Faculty rounding during the OP dialysis rotation was “prn” in 25 percent of programs.

We made a series of recommendations to improve the fellowship experience and align what fellows are taught with what they need to know when they enter practice. These include: continuity experience in outpatient dialysis (minimum of three months, preferably 12 months); exposure to all available forms of RRT including HD, PD, HDF, and CRRT; exposure to daily and nocturnal dialysis as well as HHD; exposure to interventional nephrology; regular multidisciplinary rounds with faculty and other care team members on a regular basis; and regular didactic lectures on relevant topics related to dialysis and the management of ESRD and CKD patients.

This list is now incomplete, as pointed out in the excellent study by Lane and Brown published in the same issue of CJASN as the Kohan editorial. These authors from Australia point out that in order to truly be a world class nephrologist, one must have the content knowledge, as outlined in our recommendations above, but also must be trained in delivering holistic care, in developing the necessary skills to apply the knowledge, the be sympathetic/empathetic and to be a superior communicator.

So the challenge goes to our nephrology training program directors – how can they adequately deal with the external forces outlined by Kohan, provide the content knowledge that grows every day and develop a new generation of compassionate communicators?  Not an easy task, but unless we all dedicate ourselves to helping making this possible, it will not happen and one of the last remaining great medical subspecialties will be struggling for survival.

Do the words of the late John F. Kennedy apply to nephrology of the future?

“We have the power to make this the best generation of mankind in the history of the world or to make it the last.”

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

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References:

1.    Kohan DE. Training the next generation of nephrologists. Clin J Am Soc Nephrol 6:  2564-2566, 2011.
2.    Berns JS. A survey-based evaluation of self-perceived competency after nephrology fellowship training. Clin J Am Soc Nephrol 5:  490-496, 2010.
3.    Nissenson AR, Agarwal R, Allon M, Cheung AK, Clark W, Depner T, Diaz-Buxo JA, Kjellstrand C, Kliger A, Martin MJ, Norris K, Ward W, Wish J. Improving outcomes in CKD and ESRD patients:  Carrying the torch from training to practice. Seminars in Dialysis 17:  380-397, 2004.

Ezekiel Emanuel is the oldest of three brothers, his younger brother Rahm is Mayor of Chicago and Ari is an agent in Hollywood.  Ezekiel is a physician, a bioethicist who has recently devoted his career to public policy.  He has been writing a series of editorials in the New York Times that outline his view of the current state of healthcare in the U.S. and approaches to addressing the disparities in access to care, the lack of health insurance for millions and, the real elephant in the room, the growing population of patients with multiple chronic conditions that is driving the overall expenditures on healthcare toward 18 percent of the gross domestic product (GDP).

It is this latter group that is most concerning. Representing 10percent of the population, these patients consume nearly two-thirds of all healthcare dollars.  One of the solutions suggested by Dr. Emanuel is to “bundle” payments to providers.  As he explains:  “…The idea is to force all of a patient’s care providers to work together.  They have a strong incentive to eliminate unnecessary tests and treatments and use less expensive implants, drugs and devices that don’t compromise quality, and to prevent infections and other complications that could land the patient back in the hospital…[This is] even more important…for patients with chronic illnesses…these conditions have clear, widely accepted clinical guidelines…that could form the basis for bundled payment…”

This should all sound familiar to nephrologists.  Patients with ESRD comprise less than one percent of all Medicare patients but account for nearly eight percent of all Medicare costs.  Payment for dialysis care has been bundled since nearly the inception of the program and recent changes in the reimbursement system have extended the bundle to include injectable medications, and an expanded list of laboratory tests.  If one closely examines the overall costs of dialysis patient care, however, it is clear that the current bundled payment does nothing to address the most important driver of overall costs- hospitalizations.  In fact, hospitalizations and rehospitalizations account for over 40% of the total costs of care for dialysis patients.  So does this mean that Dr. Emanuel’s concept is wrong – that bundled payments for the chronically ill are not effective in controlling costs and driving higher quality care?

Clearly the devil is in the details.  The current bundled payment system for dialysis services, by focusing on what is “dialysis-related” is inadequate to test the Emanuel hypothesis.  In fact, the renal community has already proven that bundling payments can drive better outcomes and constrain costs of care.  The recently completed CMS Demonstration Project clearly showed that by fully bundling payment to the provider, enabling the provider to invest in holistic, integrated and coordinated care to improve patient health and avoid unnecessary hospitalizations, a true win-win is created.  Patients have better outcomes and the healthcare system costs are constrained.  The most recent movement in healthcare toward ACOs is an acknowledgment by policy makers and providers that bundling payment and creating aligned incentives make sense for patients and the overall system.  Unfortunately, efforts by the renal community to persuade CMS to allow ACOs with attribution of patients because of the presence with kidney disease did not prevail, and there is great concern that our patients will be lost in a general ACO.  We hope that the Centers for Medicare and Medicaid Innovation will be more willing to allow us to build on the great success we have shown in demonstration projects in order to benefit the lives of many more of our patients.

As Thomas Edison said:  “The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease.”  Nearly a century later politicians and patients are demanding a true health care system rather than a sick care system, and for those with patients with kidney disease, it is time we stepped up and provided just such an approach.

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

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