HCFA project tests renal programs

Success could mean better treatment, less cost

Patients who have end-stage renal disease (ESRD) have lost their kidney function entirely. Their choices are limited: dialysis, kidney transplant, or death. For years, ESRD patients on Medicare had even less of a choice on where to receive their treatment since the government prohibited them from joining HMOs. And that means patients who aren't eligible for Medicaid and don't have wrap-around insurance pay substantial out-of-pocket costs every month.

But now, a three-year project sponsored by the Baltimore-based Health Care Financing Admini stration is allowing ESRD patients to enroll in three pilot programs at HMOs in Florida, Tennessee, and California. The ESRD Managed Care Demonstration Project seeks to find out if disease management programs implemented by HMOs can improve care and lower costs, says HCFA project officer Bonnie Edington. The law that set this project in motion gives the HMO a capitated rate for each patient under which the HMO must provide all the services already covered by Medicare, plus extra benefits it can choose. Patients must be given service for at least three years, and an independent research firm will evaluate the outcomes.

"Some ESRD patients average $600 a month in out-of-pocket costs with Medicare's 20% copay," Edington says. "Most HMOs can charge well below that amount. One patient heard about the program and said it just saved his house. He was about to lose it because he was in so much debt from his medical expenses."

ESRD patients got locked out when Medicare first started paying HMOs in the 1980s. "Nobody's really sure whether it was out of concern for quality or whether it was the HMOs worried about the high costs of these patients. We tried to research that but couldn't get a clear-cut answer," Edington says. "In the '80s, there was no organized message coming from the renal industry. Now, several HMOs are very eager to get ESRD patients and are less leery about being able to live with that ESRD capitation dollar."

HCFA hopes the HMOs can provide better integration of services that will lead to better clinical outcomes, Edington says. "ESRD patients have a tremendous number of hospitalizations, and we think there is room to prevent some of those things that cause the need for hospitalization," she says. "That can range from better diabetic care because diabetes is extremely prevalent in the ESRD population, to better vascular access for dialysis. If the HMO has an interest in reducing the hospitalization episodes, they might be more careful about the surgeons who are doing these procedures so they are less problematic."

There's no consensus in the field nor in HCFA about how much of these problems in the fee-for-service setting could be changed by HMOs, Edington says. Some say, for example, that the vascular access problems have nothing to do with the quality of the surgery, and it's not something that could be prevented. "We don't really know, but clearly the HMO has an incentive to do whatever's necessary," she says. "Under the demonstration project, the HMOs cannot subcontract to reduce hospitalizations willy-nilly without knowing what it was that was reduced. If there are going to be bonuses paid to the nephrologists, it must be for reducing something that we want reduced so we know whether it was appropriate."

Kaiser Permanente of Southern California, the first site to begin enrolling patients and the only one to have an existing ESRD disease management program, thinks it can improve on care for Medicare patients. Because Kaiser is so large, with more than 5 million members in California, it has had a good deal of experience with patients who develop ESRD after they enroll (and thus are not subject to the no-HMO Medicare rule), says Peter W. Crooks, MD, medical director for the HCFA project and a nephrologist at the Kaiser Permanente Medical Center in Woodland Hills, CA. About 2,300 patients were already in Kaiser's ESRD program, and the HCFA project allows open enrollment for any Medicare beneficiary in the region.

"ESRD care in the United States is not optimal," Crooks says. "We have much higher mortality rates than in European countries, so we know it's possible to do a better job."

Kaiser has already demonstrated that its renal care model can indeed do a better job at managing ESRD patients. In 1997, the mortality rate of Kaiser ESRD patients was 16.5%, compared with the 21% national mortality rate. In 1996, patients in the program averaged 7.5 hospital days a year, compared with 17 days nationally. For the HCFA project, Kaiser will continue with its established program with the extra benefits of no co-payment for medications and office visits, free nutritional supplements, podiatry and dental services, and enhanced team care.

The key to Kaiser's success in ESRD care is integrating services, Crooks says. With the fee-for-service system, care is fragmented and there's no case management. Kaiser serves patients with a medical center-based multidisciplinary team that is made up of a nephrologist, nurse, dietitian, social worker, and pharmacist. Patients come at least once each quarter for a team visit during which they see each team member on the same day in the same location. At the end of clinic days, the team meets to review patients, and findings are sent to the dialysis center and to any contract nephrologists patients might be seeing. "Patients don't get lost," Crooks says.

A full-time ESRD case manager - one for each of Kaiser's 11 southern California medical centers - makes sure patients are getting the services they need. They help with appointments and any issues not being addressed by the team. Nurses visit the dialysis units regularly to improve relationships and enhance communication. They also do monthly reporting of lab values and other pertinent patient information, educate patients, and prepare them for transplant evaluations.

"Many patients don't even know there are two different kinds of dialysis," Crooks says. "What they usually have heard of is hemodialysis, but peritoneal dialysis can be another option that would allow them to do their dialysis at home. Our nurses make sure patients have all the information they need."

[For more information on the ESRD project, contact:

· Bonnie Edington, project officer for the ESRD Managed Care Demonstration Project, Health Care Financing Administration, Baltimore, MD. (410) 786-6617.

· Peter Crooks, MD, Kaiser Permanente Medical Center, 5601 DeSoto Ave., Woodland Hills, CA 91365. Telephone: (818) 719-2485.]