Study: Financial incentives did not markedly increase patient placement on peritoneal dialysis
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Even when they were financially incentivized, nephrologists in Canada did not place more patients on peritoneal dialysis compared to hemodialysis, according to a published study.
“We identified no statistical evidence of an increase in peritoneal dialysis use following increased fee-for-service remuneration for peritoneal dialysis,” Aaron J. Trachtenberg, MD, DPhil, and colleagues wrote. “It remains unclear what role, if any, physician payment plays in selection of dialysis modality.”
The study included 4,262 patients in Alberta who started long-term dialysis between Jan. 1, 2001 and March 31, 2004 (n = 879 patients) and between April 1, 2005 and Dec. 31, 2014 (n = 3,120 patients) and had received care from a nephrologist at least 90 days prior to starting treatment. Another 263 patients started dialysis during a 1-year exclusion period.
Data from the Northern and Southern Alberta Renal Program registries were used for the study and included clinical information for all patients who received dialysis in Alberta and those with advanced chronic kidney disease who were seeing nephrologists. Additional data from the Alberta Kidney Disease Network identified patients starting long-term dialysis or receiving a renal transplant, the date of dialysis initiation and the dialysis modality. The authors used the Alberta Health administrative data to identify patient demographics and clinical details, and nephrologists’ remuneration method and other characteristics.
The nephrologists were categorized into one of two groups: those who received fee-for-service (FFS) payments for patient care and those who received their standard salary. For the FFS paid nephrologists, weekly remuneration for placing a patient on PD increased from $0 to $32 (fee change 1, Apr. 1, 2002), $49 to $71 (fee change 2, Apr. 1, 2007) and $71 to $135 (fee change 3, Apr. 1, 2009).
“We performed a patient-level differences-in-differences logistic regression, adjusted for demographic characteristics and comorbidities, as well as an unadjusted interrupted time-series analysis of monthly outcome data” to determine differences in prescribing patterns, the researchers wrote. The differences-in-differences estimator was the odds ratio for PD use in the fee-for-service group after vs. before a fee change. That number was divided by the odds ratio for PD use in the salaried group after vs. before a fee change.
“A difference-in-differences estimator greater than 1 implies that there was a greater increase in the odds of peritoneal dialysis use for a patient in the fee-for-service group than for a patient in the salaried group following a fee change. A differences-in-differences estimator less than 1 implies the opposite,” the authors wrote.
In reviewing the results, Trachtenberg and colleagues noted some change was seen in PD prescriptions after the third payment increase.
“In a sensitivity analysis, we found a significant differences-in-differences effect of fee change 3 on peritoneal dialysis use at day 90 of greater than 1, which suggests that peritoneal dialysis use increased more in patients assigned to fee-for-service nephrologists after the equalization of peritoneal dialysis and hemodialysis remuneration than it did in patients assigned to salaried nephrologists,” they wrote. “Although the effect size was small and the complementary interrupted time-series analysis was nonsignificant, this may suggest that the effects of remuneration on peritoneal dialysis use appear only when payment is at least equal [to hemodialysis]. It remains unclear whether paying physicians more for peritoneal dialysis than for hemodialysis has a meaningful effect on dialysis modality selection.” – by Mark E. Neumann
Perspective
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Martin J. Schreiber, MD
“Transformation is often more about unlearning than learning.”
– Richard Rohr
Nephrologists and kidney care team members are asking whether the United States has the right incentives in place to drive a shift to home modalities. The report by Trachtenberg and colleagues leveraged a change in physician payer reimbursement to drive home peritoneal dialysis, comparing salaried vs. FFS nephrologists. The study examined three different fee schedule adjustments in a provincially determined fee schedule during two discrete periods: January 2001 to April 2002 and April 2005 to December 2014.
Differences in characteristics between groups and within group differences before and after fee changes were examined. The authors’ concluded that increasing payment to FFS nephrologists for providing PD was not associated with a statistically significant increase in PD assignment.
There was however, a significant differences-in-differences effect of fee change 3 on PD use, suggesting that it takes an equilibration at least to in-center hemodialysis payments or greater to have a PD growth impact; relatively small scale changes in reimbursement may not be enough to alter physician behavior. While physician payer reimbursement is a barrier, especially if less than in-center hemodialysis (ICHD) payment, other factors warrant consideration, such as: clinical workload, practice location, allocated resource differences, and the length of the observation period for a financial payment effect. These factors could have impacted results in this study.
In the context of this report, the authors did not cover anything new in broadening our understanding of home modality growth through financial incentives.
The use of home dialysis in the United States has increased during the last 10 years in the setting of payment reforms and educational efforts. Differences in home dialysis use in the United States vary significantly across geographies, physician groups and specific ethnic populations and yet the reasons for these differences are unclear. As noted by Manns and colleagues, the use of financial incentives to stimulate home dialysis growth, whether directed at the dialysis facility, nephrologists or patients is only part of a well-organized system to promote home dialysis.
Several studies have demonstrated the importance of non-medical factors on ESKD modality selection. Osterlund and colleagues reviewed the potential facilitating factors, knowledge gaps and different factors which highlight the complexity of modality choice, and the varied services, expertise and tools required to support patients who are transitioning from CKD to ESKD. Seemingly, financial incentives alone would not address a large number of these themes.
Incentives designed to affect physician behavior need to be structured and coordinated to drive actual system and culture changes for the health care ecosystem managing CKD and ESKD. Incentives do drive human behavior and performance; yet, specific incentives may not be aligned to consistently drive the correct decision and may not take into account factors such as practice variations, extent of physician training/clinical experience, required supporting resources, clinical workload, socioeconomic regional differences or the percent of patients who underwent pre-dialysis patient education.
It is critical as we look to shift the ESKD focus to an at-home priority that we shape policy and practice incentives which accelerate the needed changes for a transformation. While we can champion specific actions to achieve the desired results, like physician payer reimbursement, it will take “true physician transformation,” which modifies traditional tightly held beliefs, to achieve consistent forward progress with the objectives in the executive order.
If physicians do not have a fundamental belief that is aligned with the shift to home, then specific actions like financial incentives or redesigned policies will not drive preferred treatment choice toward home modalities. In order for physicians to transform themselves and their practices, they need to accelerate gains in new knowledge and relinquish mental constructs and thinking, steeped in training and tradition that no longer apply. In actuality, it is not forgetting knowledge accumulated in the past, but rather, nephrologists need to actively choose a different mental paradigm to better guide decisions and actions going forward.
We now need to ask the question: What do we do differently?
It starts by recognizing that modality choice is a two-part process. The first is the selection of the right drug (dialysis modality) and the second resides with the ability to safely and effectively manage the modality choice in the home. Pollack and colleagues described the WHO’s six-step approach to prescribing medications. Modality choices that physicians and patients make should align with the individual therapeutic objectives, ie, preserving residual renal function, avoiding cardiac stunning, preserving cognitive function, etc. The therapy selected should be evaluated regularly for tolerance and effectiveness at meeting the initial therapeutic objectives and a change should be considered if the “drug” is no longer achieving the desired effect. Addressing the “can do it” in the home environment deserves more attention and support by the provider, leveraging internal and community resources, to make management of ESKD in the home a reality.
In the future, the potential exists for computerized clinical decision support systems (CDSS) to aid clinicians in the process of decision-making for initiating the most appropriate ESKD therapy by comparing individual patient characteristics against computerized knowledge bases. Certain kinds of clinical decision support could alert clinicians when the modality option they are about to order does not match the therapeutic objectives that drove the selection. In the future, natural language processing, in combination with machine learning and other artificial intelligence techniques, should improve some performance limitations with incorporating CDSS.
The approach to managing high-cost complex diseases is changing. Incentives positioned to drive specific physician actions that improve outcomes and reduce costs will require “unlearning the old” and acquiring “new learnings.” While payer reimbursement plays a part, physician and practice transformation will carry us forward, to a new beginning where the home modality is the right “drug” choice for an increasing number of ESKD patients.
References:
Barker-Cummings C, et al. JAMA.1995;doi:10.9778/cmajo.20190132.
Golper, TA. Clin J Am Soc Nephrol. 2018;doi:10.2215/CJN.04570417.
Lin E et al. J Am Soc Nephrol. 2017;doi:10.1681/ASN.2017010041.
Manns B, et al. Nephrol Dial Transplant. 2019;doi:10.1093/ndt/gfy223.
Mehrotra R, et al. J Am Soc Nephrol. 2016;doi:10.1681/ASN.2015050472.
Mendelssohn DC, et al. Perit Dial Int. 2004;doi:10.1177/089686080402400611.
Nissenson AR, et al. ASAIO J. 1997;43(3):143-150.
Osterlund K, et al. Sem. in Dialysis. 2014;doi:10.1111/sdi.12183.
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The Learning Healthcare System: Workshop Summary. Institute of medicine (US) roundtable on evidence-based medicine; Olsen LA, Aisner D, McGinnis JM, editors. Washington, D.C.: National Academies Press (US); 2007.
Thomas E, et al. JAMA. 2019;doi:10.1001/jama.2019.14500.
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