Call to Arms…
Article Outline
MY FELLOW RENAL dietitian, if ever there was a time to stand up, make noise, and be heard, it is now. We as renal healthcare professionals can no longer sit by in the wings as Medicare and dialysis units make policies that negatively impact our patients’ lives and outcomes. I am outraged by the changes that I have seen in the past year. I am disappointed that policies are made and implemented without thinking about how they will affect those that we serve. I am disheartened that one day, I, a family member, or a friend will have to submit to the suboptimal care that these policies have created. We, as a profession, knew that there would be changes in how we treat our patients when the bundled reimbursement plan came into effect last year. I could never imagine the turn that it would take.
As 2011 loomed, we awaited potential changes in medication protocols aimed at maximizing efficiency while decreasing costs in our dialysis units. We knew that the Medicare Quality Initiative Program (QIP), a “pay for performance” measure, would shift units’ focus to meeting those outcomes. We knew our jobs would change, but we thought that we would continue to be a valued resource and partner to our unit. We philosophized that although patient loads might increase, companies would not increase our burdens to the point that we would have to make a choice between spending time with our patients and making sure all of the required documentation set out by the Conditions for Coverage was completed. We were blindsided this year.
Last summer, word came that one dialysis company laid off a large portion of their dietitians. Layoffs were handled democratically; making sure that no demographic was targeted. Young, not so young, new, and experienced dietitians were handed their walking papers without explanation. In some cases, patient loads were doubled for the remaining dietitians. To compensate, dietitian responsibilities were reduced to lab reviews and nutrition assessments. Suddenly, our vast knowledge resource was no longer considered important; we were relegated to drones putting forth the requirements set forth by the government. Was this cut in labor force because of financial hardships? Industry financials show that this company continues to profit in the bundled environment. Did the company viewed dietitians as an expenditure, and did not see how our interactions with out patients actually improve reimbursements and decrease costs? We do not know.
The second blow also came during the summer when, after reviewing well-publicized anemia studies, Medicare dropped its requirement of maintaining a minimum hemoglobin of 10 mg/dL. Instead, it recommended that patients maintain hemoglobin levels between a level at which the patient does not need transfusion and 11 g/dL. Rightly so, Medicare has looked at limiting a patient’s exposure to erythrocyte-stimulating agents (ESAs), which may put the patient at higher cardiovascular risks; however, we know the complications and cardiovascular risks associated with hemoglobin levels <10 g/dL. Earlier studies have shown that hemoglobin levels <10 g/dL increase the incidences of left ventricular hypertophy,1 increase hospitalizations,2 decrease quality of life,3 and increase need for transfusions.4 Transplant candidate patients are at risk of developing antibodies associated with transfusions, thus reducing their chances of finding a transplant match. Working patients may find their concentration and stamina reduced, having them question their capabilities to continue work, and older patients may become too weak to cook or find that their appetites have reduced, thus increasing their nutrition risk. Pundits recommend patients discuss their symptoms with their doctors so that the health care team can correctly determine a patient’s individual hemoglobin goal,5 but this requires extensive education to the patient on the changes in policy and encouraging the patient to speak up and take control of their health. Additionally, it requires doctors to balance a patient’s need with corporate policies regarding “ideal” hemoglobin levels and ESA exposure. This may be a challenge to the doctor, as companies limit ESA doses routinely provided by requiring them to fill out extensive paperwork to justify their patients’ increased need for ESA.
Another policy set forth by Medicare this year is the decision not to include residual function in urea kinetic calculations (Kt/V). Residual function has been routinely used to tailor a patient’s dialysis prescription. Why should a patient with significant function dialyze for 4 hours when their need may be 3 and a half? I am a big proponent of more dialysis being better for patients and believe that the best dose of dialysis is daily dialysis. However, patients have lives, and dialysis is a part-time job for which they don’t get paid. We foster an environment of adherence and work with a patient to meet their financial (working), emotional, and family needs when developing a schedule to provide adequate treatments. Medicare has essentially taken individuality out of dialysis and made it a “cookie cutter” treatment. Additionally, meeting urea reduction rate (URR) levels for those with significant residual function is hard when predialysis blood urea nitrogen levels are below 30 mg/dL. Kinetic investigations are repeated often when Kt/V results meet goal, but URR does not, thus increasing lab costs to the unit.
Finally, this summer, Medicare released its proposed QIP measures for 2013, which addresses bone mineral management. With the inclusion of phosphate binders into the bundled rate beginning in 2014, Medicare is proposing that units attest whether or not they are following disease markers. There is no proposal at this time on whether the unit is treating the disease. There is no mention of disease marker goal ranges, either minimums or maximums. There is no mention of accountability that medications to treat the disease are being used. I concede that we do not yet know the “ideal” ranges for calcium, phosphorus, and parathyroid hormone, but there is enough evidence to determine levels that we should not exceed without increasing morbidity and mortality in our patients.
It is unfortunate to say that as long as Medicare is dictating the reimbursement rate, it must dictate accountability and minimum care requirements that benefit the lives of our patients. Under the current and proposed QIP, the only accountability dialysis units have is that the patient be dialyzed to achieve a URR of 65%. Under the current QIP, a patient does not need to receive ESAs, iron, or vitamin D. With the proposed 2013 QIP, a patient does not need to receive phosphate binders and other agents to treat bone disease. Under Medicare’s guise, the treatment of those with end-stage kidney disease has gone from the 21st century to the 1970s. All that we have gained in the past 30 years, we have lost.
Once again, we and our patients must put our faith in the altruism of the health care providers. We must hope that they will balance cost with outcomes, quality of life, and compassion. While I have full faith in our medical teams, what will the dialysis companies choose? How will their choices affect patient outcomes?
As we move forward in this environment, I assure you that I and the Executive Committees of both the Council on Renal Nutrition and the American Dietetic Association’s Renal Practice Group are leading the crusade to protect our patients from disparities in nutrition care. Both groups are committed to support the field of renal nutrition and will do all that we can to protect our valued positions. We are more than the food experts. We are more than drones pushing papers. We are vital to the lives of our patients. We are indispensible when it comes to improving outcomes and saving costs. What can CRN members do? Keep abreast of Medicare changes, be active and vocal within the unit, and voice your opinions and concerns during quality improvement meetings. STAND UP AND BE HEARD!
References
- Reversal of left ventricular hypertrophy following recombinant human erythropoietin treatment of anaemic dialysed uraemic patients. Nephrol Dial Transplant. 1991;6:31–37
- Hematocrit levels and hospitalization risks in hemodialysis patients. J Am Soc Nephrol. 1999;10:1309–1316
- Effects of haemoglobin normalization on quality of life and cardiovascular parameters in end-stage renal failure. Nephrol Dial Transplant. 2000;9:1425–1430
- Dose finding, double-blind, clinical trial of recombinant human erythropoietin (Chugai) in Japanese patients with end-stage renal disease. Research Group for Clinical Assessment of rhEPO. Contrib Nephrol. 1989;76:179–192discussion 212-218
- . ESA treatments in dialysis patients: where do we go now?. Dial Transplant. 2011;40:387–389
PII: S1051-2276(11)00185-3
doi:10.1053/j.jrn.2011.10.003
© 2012 National Kidney Foundation, Inc. Published by Elsevier Inc All rights reserved.
