Kidney failure and the federal government / Committee for the Study of the Medicare End-Stage Renal Disease Program, Division of Health Care Services, Institute of Medicine ; Richard A. Rettig and Norman G. Levinsky, editors.

Format:

Book

Author/Creator:

Institute of Medicine (U.S.). Committee for the Study of the Medicare End-Stage Renal Disease Program.

Contributor:

Rettig, Richard A.

Levinsky, Norman G. (Norman George), 1929-

Language:

English

Subjects (All):

United States. Medicare Bureau. End-Stage Renal Disease Program.

United States.

Chronic renal failure--Government policy--United States.

Chronic renal failure.

Medicare.

Physical Description:

xiv, 426 p. : ill.

Edition:

1st ed.

Place of Publication:

Washington, D.C. : National Academy Press, 1991.

Language Note:

English

Summary:

Since 1972, many victims of endstage renal disease (ESRD) have received treatment under a unique Medicare entitlement. This book presents a comprehensive analysis of the federal ESRD program: who uses it, how well it functions, and what improvements are needed. The book includes recommendations on patient eligibility, reimbursement, quality assessment, medical ethics, and research needs. Kidney Failure and the Federal Government offers a wealth of information on these and other topics: The ESRD patient population. Dialysis and transplantation providers. Issues of patient access and availability of treatment. Ethical issues related to treatment initiation and termination. Payment policies and their relationship to quality of care. This book will have a major impact on the future of the ESRD program and will be of interest to health policymakers, nephrologists and other individual providers, treatment site administrators, and researchers.

Contents:

Kidney Failure and the Federal Government

Copyright

Acknowledgments

Contents

PART I Overview

Summary

THE CONGRESSIONAL CHARGE TO THE INSTITUTE OF MEDICINE

BASIC ASSUMPTIONS

ESRD PATIENTS AND THEIR TREATMENT

ACCESS

ETHICS

THE PROVIDER COMMUNITY

REIMBURSEMENT AND QUALITY

Reimbursement Effects on Quality

Outpatient Dialysis Reimbursement Issues

Covered Services

Rate-Setting and Payment Policy

QUALITY ASSESSMENT AND ASSURANCE

DATA SYSTEMS

RESEARCH

NOTES

REFERENCES

1 Introduction

THE CONGRESSIONAL CHARGE

CONTEXT OF THIS STUDY

STUDY METHODS

THE ESRD PATIENT POPULATION

NATIONAL EXPENDITURES FOR ESRD

ORGANIZATION OF THE REPORT

PART II Patients and Providers

2 Perspectives of ESRD Patients

EXPERIENCES WITH RENAL FAILURE

Patient Relationships with Physicians and Staff

Patient Education

Patient-Related Services

Effect of Erythropoietin

ECONOMIC EFFECTS OF KIDNEY FAILURE

CONCLUSIONS

NOTE

REFERENCE

3 Ethical Issues

PATIENT ACCEPTANCE CRITERIA

WITHDRAWAL FROM TREATMENT

Guidelines

Advance Directives

TREATING THE PROBLEM PATIENT

CONCLUSIONS AND RECOMMENDATIONS.

4 The Patient Population

INCIDENCE AND PREVALENCE

COMPOSITION OF THE ESRD POPULATION

MORTALITY ISSUES

Unadjusted Mortality

Adjusted Mortality

Subgroup Mortality

STATE AND REGIONAL MORTALITY DATA

CROSS-NATIONAL MORTALITY DATA

PROJECTIONS TO THE YEAR 20006

5 The ESRD Patient Population: Special Groups

PEDIATRIC PATIENTS

ELDERLY ESRD PATIENTS

DIABETIC PATIENTS

HYPERTENSIVE PATIENTS

Hypertension in the United States

Relationship Between Hypertension and Hypertensive ESRD

Epidemiology of ESRD Attributed to Hypertension.

Intervention

MINORITY PATIENTS

CONCLUSION

6 Structure of the Provider Community

OVERVIEW

Outpatient Dialysis Facilities

Kidney Transplant Centers

Pediatric Facilities

CHANGING STRUCTURE OF THE OUTPATIENT DIALYSIS COMMUNITY

Hospital-Based Versus Independent Providers9

Hospital-Based Providers

Patients

Independent Providers

Not-For-Profit Versus For-Profit Providers11

Not-For-Profit Providers

For-Profit Providers

Size of Outpatient Dialysis Facilities12

Facility Ownership

PART III Access

7 Access Problems of ESRD Patients

ESRD PATIENTS NOT ELIGIBLE FOR MEDICARE

Who Are the Reported Noneligibles?

Magnitude of the Problem

Geographic Variations

Payment Sources

State Medicaid Programs

State Kidney Programs

Other ESRD Programs

Conclusions and Recommendations

MEDICARE-ELIGIBLE ESRD PATIENTS

Pediatric Patients

Elderly Patients

Barriers to Access

Information

Insurance

Transportation

Rehabilitation Services

Preventive Services

STATE REGULATIONS

Specific Limits to Access and Geographic Variations

Implications of Regulations for Access and Quality

8 Access to Kidney Transplantation

THE MEDICARE KIDNEY TRANSPLANT BENEFIT

DISTRIBUTION OF KIDNEY TRANSPLANTS

SUPPLY OF DONOR ORGANS

CONCLUSIONS AND RECOMMENDATIONS

PART IV Reimbursement and Quality

9 Medicare ESRD Payment Policy

KIDNEY TRANSPLANT SERVICES

Renal Transplant Center Reimbursement

Physician and Medication Reimbursement

OUTPATIENT DIALYSIS SERVICES

Facility Reimbursement

Historical Overview

Current Policy

Special Provisions for Home Dialysis.

Special Provisions for Recombinant Human Erythropoietin (EPO)

Physician Reimbursement

INPATIENT DIALYSIS SERVICES

Hospital Reimbursement

10 Reimbursement Effects on Quality

EFFECTS OF REIMBURSEMENT ON MORTALITY

Assessing the Effects of Reimbursement on Mortality

EFFECTS OF REIMBURSEMENT ON HOSPITALIZATION

EFFECTS OF REIMBURSEMENT ON UNIT STAFFING

What Factors Are Causing These Changes?

What Are the Consequences of These Staffing Changes?

Nurses

Technicians

Social Workers

Dietitians

Implications of Changing Staff Patterns for Quality

EFFECTS OF REIMBURSEMENT ON INNOVATION

Hemodialysis

Peritoneal Dialysis

Dialysis Research Support

SUMMARY

References

11 Outpatient Dialysis Reimbursement Issues

COVERED SERVICES IN THE COMPOSITE RATE

THE RATE-SETTING PROCESS

Timeliness of Cost Data

Sampling Versus the Universe

Medicare Part A Cost Principles

The Calculation of Cost per Treatment

Oversight of the Rate-Setting Process

FACILITY PAYMENT POLICY ISSUES

Level of Payment

Dual Composite Rate

Rebasing and Updating

Inflation (or Market Basket)

Patient Complexity (Case Mix)

Technological Advances and Productivity

Methods for Rebasing and Updating

Labor Portion of the Composite Rate

PHYSICIAN PAYMENT POLICY ISSUES

APPENDIX 1

APPENDIX 2

Dissenting View of C.R. Neu

Note

12 Quality Assessment and Assurance

PRINCIPLES OF QA

THINKING ABOUT QUALITY

Structure

Process

Outcomes

Outcomes and Process and Structure

Proximate Clinical Indicators

Functional-and Health-Status Assessments

Patient Satisfaction

Quality of Life

Adjustment for Patient Complexity.

RESPONSIBILITIES OF FEDERAL AGENCIES

Public Health Service

Centers for Disease Control

Food and Drug Administration

National Institutes of Health

Agency for Health Care Policy and Research

Health Care Financing Administration

Conditions of Coverage

State Survey Process

HSQB and the ESRD Networks

Bureau of Policy Development

Office of Research and Demonstrations

Coordination Within HCFA

Quality Assessment and Assurance Data Needs

CONTINUOUS QUALITY IMPROVEMENT

The Dialysis Facility: Practical Considerations

Examples of ESRD Quality Assurance

APPENDIX 1 QUALITY OF CARE IN ESRD: AN EXAMPLE OF A PROXIMATE CLINICAL INDICATOR

Treating Anemia in Dialysis Patients1

Potential Use as an Outcome Indicator

Potential Use as Process Indicators

APPENDIX 2 EXAMPLES OF ESRD QUALITY ASSURANCE

Dialysis Clinic, Inc., Cincinnati (DCI-C)

Greenfield Health Systems

National Medical Care, Inc. (NMC)

Reference

PART V Data And Research

13 Data Systems

HEALTH CARE FINANCING ADMINISTRATION

U.S. RENAL DATA SYSTEM

UNITED NETWORK FOR ORGAN SHARING

NATIONAL END-STAGE RENAL DISEASE REGISTRY

ADEQUACY OF DATA SYSTEMS

RECOMMENDATIONS

14 Research Needs

APPENDIXES

A Glossary

B Acronyms and Initialisms

C Commissioned Papers and Contractor Reports

Intergovernmental Health Policy Project, George Washington University

Medical Media Associates, Inc.

Urban Institute

D Survival Analysis Methods for the End-Stage Renal Disease (ESRD) Program of Medicare

GENERAL ISSUES IN SURVIVAL ANALYSIS

Overview

Examples

Identification of the Study Population

The Importance of a Comparison Group

Biased Comparisons.

Interpreting Standard Errors for Population Data

Accounting for Random Variation

Important Versus Significant

Analysis of Provider Versus Patient

Choice of Parameter for Mortality Summaries

Type I and Type II Error Issues

Projections and Extrapolations

Accuracy of Counts

ADJUSTING MORTALITY ANALYSES FOR PATIENT CHARACTERISTICS

Patient Characteristics Related to Mortality

Currently Available Data

Unavailable or Difficult-to-Evaluate Data

Multivariable Methods

Stratification

Modeling

Simultaneous Effects of Variables

Constraints on the Adjustment Process

STATISTICAL METHODS OF ANALYSIS FOR ESRD MORTALITY DATA

Descriptive Parameters for One Group

Death Proportions

Death Rates

Survival Curves

Expected Lifetimes

Comparative Parameters

Regression Models

Specific Models and Methods

Poisson Regression for Death Rates

Cox Models for Relative Rates and Survival Functions

Logistic Regression for the Probability of Death

Conditional Logistic Regression and Sampling from the Risk Set

Fully Parametric Models

Prevalent Versus Incident Cohort Analyses

Frailty

Treatment Modality

Publication of Standard Death Rates

Institutional Characteristics

Internal and External Standardization

INTERNATIONAL COMPARISONS

Limitations

Etiology

Age

Withdrawal Rates

Patient Follow-up

Directions for Further Research

E Institute of Medicine ESRD Study Committee Public Hearing, May 5, 1989, Chicago, Illinois

List of Participants

F Institute of Medicine ESRD Study Committee Public Hearing on ''Issues in Dialysis Reimbursement Reimbursement Rate-Setting

G Institute of Medicine ESRD Study Committee Workshop on ESRD Staffing, November 3, 1989, Washington, D.C.

List of Participants.

H Institute of Medicine ESRD Study Committee Workshop on Kidney Transplantation, December 13, 1989, Washington, D.C.

Notes:

Bibliographic Level Mode of Issuance: Monograph

Includes bibliographical references and index.

ISBN:

9786610203987

9781280203985

1280203986

9780309597692

0309597692

9780585155609

0585155607

OCLC:

923264687