Payment reform led to a decline in home hemodialysis patients in the United States, according to a study presented at the American Society of Nephrology’s Kidney Week 2015.

“National physician payment reform intended to improve the quality of dialysis care resulted in fewer patients receiving home dialysis,” the authors wrote in their abstract.

Nephrologists now get paid per visit with patients, up to four per month, for in-center patients. The payment for home patients, however, is less because of fewer visits. The Centers for Medicare & Medicaid Services requires that nephrologists only see home patients once a month.

Researchers led by Kevin F. Erickson, MD, of Stanford University, investigated whether a policy change in 2004, which moved physician payment for in-center hemodialysis care from a capitated to a tiered fee-for-service model, affected the use of home hemodialysis in the United States.

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The researchers used a national cohort of patients starting dialysis in the U.S. in the three years before and after payment reform, and conducted difference-in-difference analyses comparing patients with Traditional Medicare coverage (who were affected by the policy) to others with Medicare Advantage (who were unaffected by the policy). They examined whether the policy had a more pronounced influence on dialysis modality assignment in areas with lower costs of traveling to dialysis facilities.

Patients with traditional Medicare coverage experienced a 12% reduction in home dialysis use following payment reform compared to patients with Medicare Advantage. Patients living in areas with larger dialysis facilities, where payment reform made in-center hemodialysis comparatively more lucrative for physicians, experienced a 16% reduction in home dialysis use following payment reform, compared to patients living in areas with smaller dialysis facilities where payment reform made in-center hemodialysis comparatively less lucrative for physicians.

“This highlights a major failure of the policy and the importance of considering unintended consequences of future physician payment reform efforts,” the authors wrote.