Major Change in Medicare Has Limited Impact on Health of Dialysis Patients

Washington, DC (May 12, 2012) - A new Medicare initiative designed to alleviate ongoing concerns about the cost of dialysis appears to be having no immediate negative consequences on the health of people receiving dialysis, according to a presentation at the 2012 National Kidney Foundation Spring Clinical Meeting.

In January 2011, Medicare began giving dialysis providers one lump payment for each patient with end stage renal disease (ESRD) - a practice known as "bundling". As of November, 2011, there appeared to be no increase in mortality rates among Americans receiving dialysis at a nationally representative sample of 145 US facilities. (

"It may take a year or two for us to be sure that there are no other health consequences that would have a more latent impact on outcomes, but at least initially, the change seems to have a neutral effect - and that's a good thing," says Lynda Szczech, M.D, National Kidney Foundation President.

Before the bundling took effect, Medicare distributed payments to dialysis providers piecemeal, reimbursing them for charges incurred as they treated patients with ESRD. This system could have provided an incentive for providers to over-treat patients; since more than 26 million Americans over age 20 have CKD, experts have raised concerns about the growing burden dialysis will pose to Medicare.

In response, Medicare revised its payment system, choosing to bundle all reimbursements into one payment that would be 2% lower than the average amount distributed per patient in 2008, to provide incentives for providers to control costs. Although the initiative appears to cut payments to providers, they may actually see little change in income, says co-presenter Jay Wish, M.D.

Still, there may be some unintended long-term consequences of the new Medicare bundle that are important to monitor, says Dr. Wish, Medical Director of the Dialysis Program at the University Hospitals Case Medical Center and Professor of Medicine at Case Western Reserve University. Notably, the sample of 145 US facilities shows that the rate of hospitalizations among dialysis patients increased from approximately 1.5 in August 2010 to 1.9 events per year in August 2011. It's not clear why this increase - not statistically significant - may have occurred, says Dr. Wish.

Furthermore, since dialysis centers will receive one lump payment, it's important to ensure that some don't try to minimize costs in ways that hurt patient health - such as discharging more expensive patients, says Dr. Wish. "Cherry-picking is probably the biggest concern under bundling. Experts haven't seen evidence of that yet, but it's early yet, so it's something they will be closely monitoring."

Since the bundle provides incentives to train patients to receive dialysis at home, it will also be important to ensure that providers don't send people to home training who are inappropriate candidates. Monitors must also guarantee that the bundle payment doesn't discourage innovation by causing dialysis providers to avoid prescribing any future beneficial drugs that are more expensive than less effective counterparts, says Dr. Wish.

In 2014, dialysis providers will be required to dispense oral drugs to patients, which could be very burdensome for the small and medium-sized clinics that do not own their own pharmacies, notes Dr. Wish. Approximately one-third of dialysis clinics may find themselves struggling to establish relationships with pharmacies and continue to monitor all the possible drug-drug interactions with prescriptions patients are receiving elsewhere, he says. "The dialysis community should work on a resolution with their state regulators to minimize any potential risks to patients."

The National Kidney Foundation is dedicated to preventing and treating kidney and urinary tract diseases, improving the health and well being of individuals and families affected by these diseases and increasing availability of all organs for transplantation.

For more information about kidney disease and dialysis contact the National Kidney Foundation at