A few weeks ago, a small-framed, longstanding diabetic patient of mine started dialysis sooner than planned. She had severe peripheral arterial disease that precipitated kidney failure from CKD 4, with bilateral lower extremity limb threatening ischemia, and a complex hospitalization. Plans for an elective start on peritoneal dialysis had to be set aside in part for medical and in part for social reasons. Her status has improved, but much remains before her, and, for the moment, she is on in-center hemodialysis.

She has commented with concern on the harried and, to her eyes, tight staffing of the unit, the void left by a social worker just departed, and her need for support beyond what her family can provide. She is worried too by the paucity of choice with respect to surgeons to provide her support for her dialysis access needs, and her vascular disease.

This first experience as a patient on dialysis is not so uncommon. In many dialysis units, staff turnover is higher than anyone would like. Community resources are often constrained by medical economics and demographics. As a Medical Director of a dialysis unit, I am deeply concerned and involved with the balance of needs for patients, for staff, and for facilities and the nephrologists who work in them.  Soon now, we will have to confront the effects of a deep cut in dialysis facility reimbursement.

Quality will be affected

As much of the U.S. kidney care community recently learned, the proposed rule for the 2014 ESRD Prospective Payment System (PPS) results in a profound cut in dialysis facility reimbursement that seems certain to threaten the quality of patient care at some facilities and endanger the viability of others. To briefly review, the proposed rule implements the 12% reduction in ESRD drug and biological reimbursement that was mandated by the American Taxpayers Relief Act of 2012 (ATRA); this, when adjusted by the annual market basket value for 2014, leads to an approximate 9.4% payment cut.

In New Mexico, we have a number of far-flung, smaller, rural dialysis units, whose economic viability is marginal today. Cuts of this magnitude will make their ability to stay open difficult at best. Across the United States, in-center dialysis units in many settings have marginal economics, and are sustained by committed providers who shift aggregated funds to continue to provide needed access to dialysis. Advocacy efforts by groups like the RPA, together with the entire kidney community, have been vigorous; hopefully these efforts may result in a positive change in the legislative or regulatory arenas by the time the final rule is published in November. However, for now, it is appropriately prudent to presume that the reduction will occur; in this way, the nephrology community can try to plan for the future and ensure that in this fiscally constrained environment, the quality of dialysis patient care provided is not compromised.

For decades, even minor Medicare payment increases for dialysis care required specific Congressional legislation. That became cumbersome and a challenging process from which to plan for the future. For this reason, the ESRD PPS can be considered a positive development. However, recent budgetary realities have highlighted significant issues. Congress has implemented methodologically-based payment cuts to the PPS in order to pay for other Medicare program funding priorities, most notably the temporary physician reimbursement fix (Sustainable Growth Rate) that has been annually approved by the House and Senate over the past several years. These reductions are in addition to the 2% cut by the sequestration law implemented April 1. Cuts of this magnitude substantially impact provision of quality patient care and challenge the nephrology community.

In my role as a private practice nephrologist in New Mexico for many years, I have served as medical director of dialysis units. Like many of my colleagues, I juggle daily my responsibilities as clinician, parent, dialysis unit medical director, husband, and community member. I happily confront the daily effort to make a positive difference in the lives I touch and struggle to ensure my patients receive the excellent care they expect and deserve. In this climate of change, ensuring dialysis facilities have the adequate resources and reimbursement to support this mission is challenging. Like many of you, I am often frustrated with the difficulty in providing the care needed by my patients and the support needed by my staff in a time of dwindling resources and reimbursement. I believe it is essential to continue to focus on these priorities in the current environment and to remember that provision of quality medical care comes first and foremost.

The role of the medical director

How does a facility ensure that the delivery of high quality kidney patient care is maintained in the face of substantial budgetary constraints? RPA believes that the dialysis facility medical director will play a paramount role in this effort. Board certified nephrologists are specifically trained to provide oversight of patients in both an acute and chronic outpatient setting, along with implementing quality improvement and pharmacological management of ESRD patients. Medical directors can draw on their skill set for managing chronic disease by helping clinics balance diverse patient needs within an environment of diminishing resources. I have continued to work with the dialysis unit/dialysis provider to maintain staffing, availability of multiple shifts, equipment, and physical surrounding of the unit itself. The medical director of the dialysis unit requires this essential training. In addition, in conjunction with interdisciplinary care teams, the dialysis facility medical director is responsible for a myriad of processes and outcomes within the dialysis unit, such as ensuring conformance with federal regulations, maintenance of safety and well-being of the patients and staff, quality improvement, maintaining a standard of professionalism, and providing appropriate leadership within the unit and for the entire community. To a substantial degree, accountability for the quality of patient care in all dialysis units in the U.S. begins and ends with the facility medical director.  [More information on the role of dialysis facility medical directors may be found in two RPA documents on this topic: RPA Position Paper on Dialysis Facility Medical Director Responsibilities under Revised CMS Conditions for ESRD Facilities (www.renalmd.org/catalogue-item.aspx?id=778), and RPA White Paper on Medical Director Responsibilities for Inpatient Hemodialysis and Other Extracorporeal Services (www.renalmd.org/catalogue-item.aspx?id=4276).]

RPA is working hard, together with the rest of the kidney care delivery community, to obtain relief from the proposed PPS cuts. RPA believes that reductions of this magnitude, on the heels of the other reductions in recent years, will threaten patient access to high quality kidney disease care. Our concern with the quality of kidney patient care is what leads RPA to underscore the important responsibilities of nephrologists  as medical directors in dialysis facilities. The high degree of medical complexity of the typical dialysis patient, in addition to the roles and responsibilities of the medical director, require specialized skills that make nephrologists by far the most qualified individuals to serve as dialysis facility Medical Directors. Their roles, responsibilities, and compensation for their expertise must be maintained, since the well being of our patients is of utmost importance.

My service within the RPA began with my need to be a part of the solution, to help navigate the direction of inevitable change, and to ensure we do not lose focus of our ultimate goal as nephrologists—the provision of excellent kidney care. I would encourage all of you to participate in this process as well. It is essential that we maintain our independence, ethics and principals, and excellence in our roles and responsibilities as nephrologists and dialysis unit medical directors, especially in challenging times such as these. Engaging with the RPA in advocating redress of the ESRD PPS proposed 9.4% cut and support for maintaining our critical role as independent dialysis unit medical directors is one way we can make a difference. Become involved in the process. Communicate your concerns to legislators and policy makers. Only with the support of our community and a firm commitment to our goals can we effect change and ensure nephrology patients continue to be well served in the years to come.