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A Time for Lemonade?
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%RIC "ERGER
! 4IME FOR ,EMONADE
!
cross the U.S., states are facing an unprecedented budget crisis. The economic downturn and housing upheaval have had a profound impact on tax revenues, just as demand for public support services has grown. The result is what some experts estimate is a combined state deficit of nearly $200 billion. This crisis has forced state officials to pick from a small menu of unpalatable options: budget cuts, tax increases or, often, a combination of the two. Gone, at least for now, are the days when State Legislatures were able to focus on positive reforms. Now, state budget cuts and tax hikes dominate the agenda. Even with all eyes turned to the fiscal crisis, the path to solvency is difficult. Just ask Governor Schwarzenegger and the California Assembly. Confronted by a crippling deficit, the Golden State has been compelled to issue IOUs in lieu of checks and is on the brink of what some are calling a full-scale budget meltdown. Talk about the proverbial bushel of lemons! But as the old saying goes, when life hands you lemons, make lemonade. Trite? Perhaps. And yet, there might just be something of value in that cliché, at least as it relates to health care policy. State officials are cutting Medicaid spending at a furious clip. As caregivers and advocates, it is logical to see this as a threat that must be combated. But the reality is that no lawmaker wishes to slash healthcare funding for its own sake. Rather, they are finding it necessary to do so because of the fiscal environment in which they are operating. Put another way, if there were an alternative option available to them – one that would decrease spending without harming patients or the healthcare delivery system they depend on – lawmakers would take it. Fortunately, there is. One of the arenas that offers real promise to state officials is vascular access for patients with End Stage Renal Disease (ESRD). Increasingly, lawmakers are becoming aware of the problems of today – and the possibilities for tomorrow. As is well known within this community, high catheter use among ESRD patients is associated with increased infection, morbidity, mortality and hospitalizations (Pastan, Soucie, & McClellan, 2002; Pisoni, et al. 2002). Patient mortality rates in the first year of dialysis have improved little over the past decade, with a persistently high mortality rate in the first 4 months of a patient starting dialysis (United States Renal Data System/USRDS, 2008). The vulnerability of incident patients in the initial months of dialysis is due to many reasons. Many patients are completely unaware they have kidney disease until they are uremic and require emergent hospital care, and patients often do not receive pre-dialysis medical care (Wingard, et al. 2007).
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Yet another key factor is the high rate of catheter use among incident patients. In fact, it is estimated that over 80% of all incident patients start on dialysis with a catheter (Lenz, Sadhu, Fornomi, & Asif, 2006). This is of more than passing interest to lawmakers. Not only does the high rate of catheter usage place their constituents at greater mortality risk, but the costs associated with catheters are much higher than those of AV fistulas and grafts. According to the United States Renal Data System (USRDS), the annual per patient cost of a dialysis patient using a catheter is nearly $18,000 greater than that of a patient with a fistula and $5,500 greater than that of a patient with a graft due to increased hospitalizations and complications (USRDS, 2006). As a result, states are increasingly focusing on vascular access reform as a way to simultaneously improve clinical outcomes and reduce state spending. One shape this reform may take is a Vascular Access Initiative that is now being seriously considered in one state and is likely to be explored by others as well. (Identification of the state is being withheld because at the time of this printing, the state had not yet announced its plans.) The objective of this Initiative is “to enhance the quality of care and save costs for the treatment of Medicaid beneficiaries in pre-dialysis status and on dialysis by improving vascular access through early identification, referral, access placement and ongoing management.” In this state, multiple barriers exist which prevent dialysis patients from starting dialysis with a permanent vascular access, and its fistula prevalence rate falls well below the national goal set by the CMS Fistula First program (Arteriovenous Fistula First, n.d.). To correct this situation, the Vascular Access Initiative will enable primary care physicians, nephrologists, and other physicians and physician extenders to enroll patients with Chronic Kidney Disease (CKD) Stage IV and End Stage Renal Disease into the program, with assistance provided by dialysis facilities. The program will have several key features: • A public-private education program utilizing printed materials, community forums, clinical training, and a public awareness campaign to promote non-catheter vascular access. • Adjustment of the Medicaid CPT rate for fistula placement to match the Medicare rate. • Provision of a one-time fee to the referral source for each patient converted from a catheter to a workable fistula or graft. • Use of existing quality measure reporting tools to evaluate the success of the program in improving the quality of care.
DOI: 10.2309/java.14-3-4
2009
Due to the cost of catheters, it is to be anticipated that this Initiative could generate significant savings for Medicaid programs. In the case of the state examining this Initiative, the projected savings exceed those which would result from a Medicaid cut also being considered by the state – by a considerable margin. As a result, the Vascular Access Initiative has the potential to be adopted in lieu of a Medicaid cut or as a means for generating savings to restore Medicaid funding reduced by a cut. A final note: Kidney Care Partners (KCP) – the nationwide coalition of kidney patients, advocates, providers and suppliers – recently introduced the PEAK Campaign to equip providers with tools to help first-year dialysis patients better transition to dialysis and improve their health and survival. The PEAK Campaignʼs goals are to reduce incident patient mortality by 20% over the next three years which could extend, even save, as many as 10,000 lives, reduce hospitalizations, and lower Medicare and Medicaid costs. Like the KCP, the Association for Vascular Access is doing vital work in this arena. Members of the vascular access community, therefore, face both a serious challenge and an exciting opportunity. Through engagement in these advocacy efforts in states across the US, AVA members can advance innovative solutions like the Vascular Access Initiative that improve clinical quality, strengthen patient outcomes, and reduce public costs. And that could make for a very appealing pitcher of lemonade for state officials in the months and years to come.
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Vol 14 No 3
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References Arteriovenous Fistula First. (n.d.). Coalition Goals. Retrieved July 15, 2009 from http://www.fistulafirst.org/about_us/ goals-press.php Lenz O, Sadhu S, Fornomi A, & Asif A. (2006). Overutilization of Central Venous Catheters in Incident Hemodialysis Patients: Reasons and Potential Resolution Strategies. Semin Dial, 19,543-550. Pastan, S., Soucie, J.M. & McClellan, W.M. (2002). Vascular access and increased risk of death among hemodialysis patients. Kidney International, 62, 620-626. Pisoni, R.L., Young, E.W., Dykstra, D.M., Greenwood, R.N., Hecking, E., Gillespie, B. (2002). Vascular access use in europe and the united states: Results from the DOPPS. Kidney International, 61,301-316. United States Renal Data System (USRDS). (2008). Annual Report. Retrieved July 15, 2009 from http://www.usrds.org/ Wingard, R., Pupim, L., Ikizler, A., Krishnan, M., Shintani, A., Ikizler, A. et al. (2007). Early intervention improves mortality and hospitalization rates in incident hemodialysis patients: Rightstart program. Clinical Journal of the American Society of Nephrology, 2, 1170-1175.
2009
%RIC "ERGER
! 4IME FOR ,EMONADE
!
cross the U.S., states are facing an unprecedented budget crisis. The economic downturn and housing upheaval have had a profound impact on tax revenues, just as demand for public support services has grown. The result is what some experts estimate is a combined state deficit of nearly $200 billion. This crisis has forced state officials to pick from a small menu of unpalatable options: budget cuts, tax increases or, often, a combination of the two. Gone, at least for now, are the days when State Legislatures were able to focus on positive reforms. Now, state budget cuts and tax hikes dominate the agenda. Even with all eyes turned to the fiscal crisis, the path to solvency is difficult. Just ask Governor Schwarzenegger and the California Assembly. Confronted by a crippling deficit, the Golden State has been compelled to issue IOUs in lieu of checks and is on the brink of what some are calling a full-scale budget meltdown. Talk about the proverbial bushel of lemons! But as the old saying goes, when life hands you lemons, make lemonade. Trite? Perhaps. And yet, there might just be something of value in that cliché, at least as it relates to health care policy. State officials are cutting Medicaid spending at a furious clip. As caregivers and advocates, it is logical to see this as a threat that must be combated. But the reality is that no lawmaker wishes to slash healthcare funding for its own sake. Rather, they are finding it necessary to do so because of the fiscal environment in which they are operating. Put another way, if there were an alternative option available to them – one that would decrease spending without harming patients or the healthcare delivery system they depend on – lawmakers would take it. Fortunately, there is. One of the arenas that offers real promise to state officials is vascular access for patients with End Stage Renal Disease (ESRD). Increasingly, lawmakers are becoming aware of the problems of today – and the possibilities for tomorrow. As is well known within this community, high catheter use among ESRD patients is associated with increased infection, morbidity, mortality and hospitalizations (Pastan, Soucie, & McClellan, 2002; Pisoni, et al. 2002). Patient mortality rates in the first year of dialysis have improved little over the past decade, with a persistently high mortality rate in the first 4 months of a patient starting dialysis (United States Renal Data System/USRDS, 2008). The vulnerability of incident patients in the initial months of dialysis is due to many reasons. Many patients are completely unaware they have kidney disease until they are uremic and require emergent hospital care, and patients often do not receive pre-dialysis medical care (Wingard, et al. 2007).
132
|
JAVA
|
Vol 14 No 3
|
Yet another key factor is the high rate of catheter use among incident patients. In fact, it is estimated that over 80% of all incident patients start on dialysis with a catheter (Lenz, Sadhu, Fornomi, & Asif, 2006). This is of more than passing interest to lawmakers. Not only does the high rate of catheter usage place their constituents at greater mortality risk, but the costs associated with catheters are much higher than those of AV fistulas and grafts. According to the United States Renal Data System (USRDS), the annual per patient cost of a dialysis patient using a catheter is nearly $18,000 greater than that of a patient with a fistula and $5,500 greater than that of a patient with a graft due to increased hospitalizations and complications (USRDS, 2006). As a result, states are increasingly focusing on vascular access reform as a way to simultaneously improve clinical outcomes and reduce state spending. One shape this reform may take is a Vascular Access Initiative that is now being seriously considered in one state and is likely to be explored by others as well. (Identification of the state is being withheld because at the time of this printing, the state had not yet announced its plans.) The objective of this Initiative is “to enhance the quality of care and save costs for the treatment of Medicaid beneficiaries in pre-dialysis status and on dialysis by improving vascular access through early identification, referral, access placement and ongoing management.” In this state, multiple barriers exist which prevent dialysis patients from starting dialysis with a permanent vascular access, and its fistula prevalence rate falls well below the national goal set by the CMS Fistula First program (Arteriovenous Fistula First, n.d.). To correct this situation, the Vascular Access Initiative will enable primary care physicians, nephrologists, and other physicians and physician extenders to enroll patients with Chronic Kidney Disease (CKD) Stage IV and End Stage Renal Disease into the program, with assistance provided by dialysis facilities. The program will have several key features: • A public-private education program utilizing printed materials, community forums, clinical training, and a public awareness campaign to promote non-catheter vascular access. • Adjustment of the Medicaid CPT rate for fistula placement to match the Medicare rate. • Provision of a one-time fee to the referral source for each patient converted from a catheter to a workable fistula or graft. • Use of existing quality measure reporting tools to evaluate the success of the program in improving the quality of care.
DOI: 10.2309/java.14-3-4
2009
Due to the cost of catheters, it is to be anticipated that this Initiative could generate significant savings for Medicaid programs. In the case of the state examining this Initiative, the projected savings exceed those which would result from a Medicaid cut also being considered by the state – by a considerable margin. As a result, the Vascular Access Initiative has the potential to be adopted in lieu of a Medicaid cut or as a means for generating savings to restore Medicaid funding reduced by a cut. A final note: Kidney Care Partners (KCP) – the nationwide coalition of kidney patients, advocates, providers and suppliers – recently introduced the PEAK Campaign to equip providers with tools to help first-year dialysis patients better transition to dialysis and improve their health and survival. The PEAK Campaignʼs goals are to reduce incident patient mortality by 20% over the next three years which could extend, even save, as many as 10,000 lives, reduce hospitalizations, and lower Medicare and Medicaid costs. Like the KCP, the Association for Vascular Access is doing vital work in this arena. Members of the vascular access community, therefore, face both a serious challenge and an exciting opportunity. Through engagement in these advocacy efforts in states across the US, AVA members can advance innovative solutions like the Vascular Access Initiative that improve clinical quality, strengthen patient outcomes, and reduce public costs. And that could make for a very appealing pitcher of lemonade for state officials in the months and years to come.
134
|
JAVA
|
Vol 14 No 3
|
References Arteriovenous Fistula First. (n.d.). Coalition Goals. Retrieved July 15, 2009 from http://www.fistulafirst.org/about_us/ goals-press.php Lenz O, Sadhu S, Fornomi A, & Asif A. (2006). Overutilization of Central Venous Catheters in Incident Hemodialysis Patients: Reasons and Potential Resolution Strategies. Semin Dial, 19,543-550. Pastan, S., Soucie, J.M. & McClellan, W.M. (2002). Vascular access and increased risk of death among hemodialysis patients. Kidney International, 62, 620-626. Pisoni, R.L., Young, E.W., Dykstra, D.M., Greenwood, R.N., Hecking, E., Gillespie, B. (2002). Vascular access use in europe and the united states: Results from the DOPPS. Kidney International, 61,301-316. United States Renal Data System (USRDS). (2008). Annual Report. Retrieved July 15, 2009 from http://www.usrds.org/ Wingard, R., Pupim, L., Ikizler, A., Krishnan, M., Shintani, A., Ikizler, A. et al. (2007). Early intervention improves mortality and hospitalization rates in incident hemodialysis patients: Rightstart program. Clinical Journal of the American Society of Nephrology, 2, 1170-1175.
2009