Renal community looks back, prepares for future in the treatment of AKI
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In 2017, CMS changed the script for caring for patients diagnosed with AKI.
The agency reduced the length of stay in the hospital by providing outpatient dialysis centers an opportunity to care for these patients. Payment per treatment for patients with AKI was equal to patients who were on maintenance dialysis.
We began taking patients with AKI shortly after the new regulations were final and we have treated 139 patients at Independent Dialysis Group to date. As a dialysis provider that cares for 250 patients with end-stage kidney disease, we embraced providing dialysis for those with AKI. In October 2016, we opened our transitional care facility on a nearby hospital campus. Our design included the nephrologist’s office, home therapies training space and a 12-station unit all under one roof. We had two separate addresses to keep office and facility billing separate, but we shared a lobby and a breakroom to maintain a cohesive feeling between facility and office staff.
In addition to providing AKI treatments, our kidney center also dialyzes the highest acuity patients from all our facilities. We reduced our registered nurse-to-patient ratio to 8:1 and our patient care technician-to-patient ratio to 3:1 to provide more intense clinical oversight for each patient.
In the last 4 years, we have helped 58 patients (42% of our AKI population) regain kidney function. Nine of these patients (6% of our AKI population) trained for peritoneal dialysis. The average time of their modality change was 20 months since they were diagnosed with AKI, despite having daily contact with our nephrology and home therapies teams.
We thought it would take less time to convince patients to choose PD.
To date, 40% of our AKI population has been female and 60% male. The average age for patients with AKI has been 66 years old. The average age of our current patient population on PD is 62 years and this is evenly divided between men and women.
In 2019, we saw a surge of patients with AKI in our facility (see Table 1). Then in 2020, we experienced a significant decline, most likely an impact of the COVID-19 pandemic with fewer elective surgeries, fewer diagnostic interventions and limited referral of patients with chronic kidney disease.
As 2021 unfolds, we are on track to care for more patients with AKI than we did in 2019.
The average time for our AKI population to regain kidney function was 48 days. We had four outlier patients who transitioned to ESRD, but subsequently regained function between 87 days and 144 days after the diagnosis of AKI.
At Independent Dialysis Group, 75% of our patients with AKI had Medicare or were on a Medicare Advantage plan and 17% had either a Medicaid or Medicaid Advantage plan as their insurance. As in other areas of renal care, Medicare policy drives action and change.
AKI recovery
When we planned to care for patients with AKI, we tried to think of everything. We braced ourselves for the experience and ramped up our clinical labor ratios to assist with the challenge. What we did not expect was the overall morale boost patients with AKI brought to our outpatient center.
Almost half of the patients we cared for regained kidney function. For the most part, they represented “wins” for our clinical staff who are more accustomed to a chronic renal replacement therapy (RRT) outcome.
Transplants also represent a “win” but these occur less frequently; and even that is changing largely because of the CMS focus outlined in the ESRD Treatment Choices (ETC) model.
PD for patients with AKI
CMS is now assessing the value of PD urgent starts for treating patients with AKI in the outpatient setting. CMS has focused on the placement of the PD catheter as a major barrier to patients when adapting PD for acute therapy.
The agency solicited the renal community for comments on the possibility of increasing the reimbursement for PD catheter placement specifically for the ETC model. This is because PD catheter placement has the lowest RVUs and reimburses the least of all dialysis access procedures. These catheters are placed by vascular surgeons, interventional radiologists and interventional nephrologists.
It has been my experience that the first two specialists are not always invested in timely PD catheter placement. It is no wonder why CMS is starting its PD urgent start efforts on this stage of the process.
However, CMS should reconsider this approach so the benefit can impact more than just the markets participating in the ETC model. Rather, extend it to the entire renal community. A disparate payment for PD catheter placement in the ETC model skews data in the control group negatively and creates a different opportunity for Medicare beneficiaries to have a catheter placed.
Payment issues
When CMS introduced AKI to the outpatient community, the agency pegged the reimbursement rate to the ESRD base rate. In 2020, CMS increased the base rate for ESRD treatments, and the AKI base rate followed.
The current PD urgent start prescription requires AKI patients to dialyze 5-8 hours every other day over a 2–3-week period. If a dialysis provider has multiple training rooms that can be observed centrally, then a single nurse may care for several patients at one time; if not, the nurse is caring for one patient at a time. If the PD urgent start is done in a traditional hemodialysis center, it will consume a single station for two shifts. There is a higher cost of care in either scenario that should be recognized and reflected in the AKI base rate.
Transitional unit
I believe we set up the perfect transitional care facility at Independent Dialysis Group. We provided all of the clinical ingredients to aptly educate patients about different modalities and transplant opportunities. Despite this, we had two patients with AKI train and successfully change their modality to PD.
The amount of education required to convince patients that their disease might be permanent and that they should plan for the long term is staggering. One statistic I am not proud of is that 20 patients with AKI (14% of our AKI population) elected to have their catheter removed and an arterio-venous fistual/arterio-venous graft created. It took a lot of our team’s focus and education to move the needle that far, primarily because most patients do not want to accept that their AKI has become ESRD.
If we are going to convince this population that PD is a good option, it is going to take education, as well as financial incentives for PD catheter placement, both of which require additional resources. I urge CMS to consider this hurdle as it develops a plan of attack.
- Reference:
- Ghaffari A. Am J Kidney Dis. 2012;doi:10.1053/j.ajkd.2011.08.034.
- For more information:
- Adrian Amedia, MHA, CMPE, is an owner of Independent Dialysis Group, based in Youngstown, Ohio. He can be reached at 330-781-6212.
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