A Minimum Outcomes bill?

I’ve been emailing a long-time member of DialysisEthics and he suggested it might be a good idea to work on getting a bill for minimum outcome standards. In order for the center to get paid the full amount dialyzors would have to have, for example, a KTV of 1.4 or higher. If it was lower, the clinic would get paid on a sliding scale, 95% etc…

I’ve got some friends involved in politics and I’ve thought about approaching them with the idea, but I wanted to get some feedback first.

I did also start a topic at the DialysisEthics site:


Hi Plugger,

CMS has been moving in exactly this direction for some time now. They call it “pay for performance” (P4P). The question is exactly what standards they’ll use. Kt/V is actually not all that important–all it measures is removal of urea, a small molecule that is easily removed and doesn’t reflect other toxins that are much more harmful. The ESRD Program within Medicare is a microcosm that they seem to be using for studying the bigger picture of healthcare. So, “bundling” came first to ESRD before being imposed on other aspects of health, and P4P will likely come to ESRD first, too.

I’m not sure any other bill is needed, since this is already in the plans.

Hmm, day late and a dollar short. Great to hear things are moving along though! I guess we will stick to our individual patient advocacy forte for now.

Many Nephrologists believe that the KTV is bad science.

Many nephrologists are right, IMHO! It makes very little sense to choose a tiny molecule that freely moves between cell walls as an index of how good dialysis is, when MOST of the molecules that need to be removed to keep you feeling your best are large and/or twisty and complex and much harder to get rid of. Kind of like having a septic tank cleaned by siphoning off the liquid on top while leaving all of the SLUDGE at the bottom…

So you don’t think much of this reporting they are doing for dialysis adequacy starting this July?


Good question, Plugger. I don’t think CMS can drop it until some new dialysis dose standard is agreed upon and backed up by science. But this doesn’t even call for Kt/V–it’s URR, which doesn’t even account for body size! This is just bad science–and the whole concept of “adequate” dialysis is poorly conceived. Would you want “adequate” time on a heart-lung machine (perhaps 3 days a week?!). If we’re replacing kidney function, we should replace kidney function as physiologically as we can, given cost constraints and data about outcomes. We know that 3x/week short treatments (<4 hours) contribute to tens of thousands of needless deaths just in the U.S. So why is this the standard of care? Why isn’t there a minimum TIME requirement for treatments?.

The folks I know at CMS who work in the ESRD area truly do care about patients and want to do the best they can for them. But we need sweeping changes to the way dialysis is measured and delivered in this country, and the way patients are educated, if we want to give people back their lives and justify the very high costs of this treatment. Measuring URR is never going to get us there.

The CMS policy to collect URR was required by Congress when it passed the Medicare Improvements for Patients and Providers Act (MIPPA). The program that was known as “pay-for-performance” is now known as the Quality Incentive Program (QIP). The transmittal appears to show that CMS is moving from URR to Kt/V. The policy section states:
The CMS will require the reporting of the Kt/V reading and date of the reading, vascular access and infection data on ESRD claims with dates of service on or after July 1, 2010. This new data reporting requirement will allow CMS to implement an accurate quality incentive payment for dialysis providers by January 1, 2012, as required by MIPPA §153c. CMS is requesting a July 2010 implementation date because the quality incentive payment must be in part based on provider improvement over time, thus, CMS requires an accurate measurement of baseline provider performance. The CMS will require that providers continue to report the existing G1 through G6 modifiers for URR at this time.

In my opinion, there is a much better way to tell if patients are receiving optimal dialysis. Instead of using lab tests to measure what’s in a a patients’ blood, why not ask patients about their physical and mental functioning and how kidney disease affects their life, collect data on the percentage of pediatric patients that are in school, the percentage of working age patients who are working, the percentage of retirees who live active lives, and the percentage of patients who have correctable limitations that have not been addressed?

Instead of cheering that poor performing facilities will have their reimbursement cut, I’d wonder if there isn’t a better way. What about using behavior modification? Remember the saying, “You can get more from honey than vinegar?” Why not try positive reinforcement instead of punishment. Set goals that take effort to meet. Pay 1-2% more to facilities that meet those goals. Move the goals higher as more facilities meet the goals. It might just save Medicare money if patients do better, are hospitalized less, have fewer complications, are able to work and pay taxes. The way the system is set up now, when CMS pays poor performers less, those providers will just become easier targets for acquisition by large dialysis organizations which will become larger and more powerful, making them able to donate more to politicians to get policies that work best for them. Just a thought…

I think you hit the nail on the head! Longer is better! Maybe pay so much for the first few hours, then a bit less for more time? My impression is in-clinic slow nocturnal could be the ideal for many people.

I like it! A lot of what you are saying sounds easy enough to measure.