Medicare for years has tested new ideas on outpatient dialysis centers, and this experience could help hospitals that are embarking on bundled payment for joint replacement and cardiac care, says Brendan Bowman, M.D., University of Virginia Health System regional medical director for dialysis.

People on dialysis, regardless of age, are covered under Medicare, making dialysis subject to a single-payer system. “All the quality ideas that the Centers for Medicare & Medicaid Services wants to try out, they first give it a go in the dialysis community,” he says. “Value-based purchasing, quality incentive programs with reductions — all of these things were tried out first with us. We’re a pretty captive audience.”

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Since 2011, outpatient dialysis providers, regardless of ownership, have received bundled payment for dialysis. The payment includes drugs, lab services, supplies, capital-related costs and a training add-on for home and self-dialysis modalities.

“There was some rough and tumble when the program first came around — what medications count in our bundle and which things don’t — but the relationship overall between the dialysis system and CMS has been a good one,” Bowman says.

Now dialysis facilities know how to survive within a bundled payment system, he adds. “So, as things like orthopedics and joint replacement move toward bundled payment, if they have a dialysis system, there are a lot of lessons to be learned about how to manage and budget within a bundled payment system that dialysis systems can offer as a vanguard of that process.”

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Dialysis providers were on the leading edge of CMS quality incentive programs. Under Medicare’s End-Stage Renal Disease Quality Incentive Program, centers can lose up to 2 percent of payment for failing to meet measures. In 2017, the program includes 11 measures — eight clinical and three reporting.

Medicare generally follows the lead of quality and safety experts in the dialysis community when arriving at quality measures, Bowman says. “CMS says, ‘There is a large portion of your community that thinks this is important for patient safety, let’s put this in the QIP,’” Bowman explains. “Then hopefully the outliers start to fall into place. By putting a financial framework around it, the program really helps to boost the importance of quality in the care of dialysis patients.”