Cover Image

HARDBACK
$49.95



View/Hide Left Panel

INDEX

A

Abandonment of patients, 58

Access to care

barriers to, 150-157, 177

certificate of need and, 10, 158-163

defined, 335

dialysis patients, 135-164

donor organ supply and, 179-182

education/information and, 150-152

elderly patients, 150, 175

exclusion of individuals for medical reasons, 178

geographic variation in, 138-140, 160-162

and ineligibility for Medicare benefits, 6-7, 136-148

insurance coverage (private) and, 152-154, 172-173, 177-178, 330

magnitude of problem, 138

Medicare-eligible patients, 148-157

and payment sources other than Medicare, 140-146, 177-178

pediatric patients, 115, 149-150, 175, 176

preventive services, 156-157

rehabilitation services, 155-156

state regulations and, 158-163

transplants, 7-8, 167-185, 187

transportation and, 154-155

Activities of daily living, 335, 284

Advance directives, 56, 59-60, 335

Age

and acceptance for treatment, 8, 52-53

and diabetic kidney disease, 90, 93

and employment of ESRD patients, 155

ESRD patient trends, 27, 64, 65, 67-68, 70, 91, 100, 150, 216

and health insurance coverage, 152

and hypertension, 95

and hypertensive ESRD, 90, 95-98

and mortality rates, 72, 74, 76-78, 213

and treatment modality, 91, 92, 168

and transplants, 168, 175, 176

see also Elderly patients;

Pediatric patients

Agency for Health Care Policy and Research, QA responsibilities, 276, 287-288

AIDS, 53, 178, 179-180, 184, 252, 286

Albuminuria screening, 94

Alternative Reimbursement Method, 202-203

American Diabetes Association, 94-95

American Medical Association, 202

American Outpatient Services Corporation, 129



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 411
Kidney Failure and the Federal Government INDEX A Abandonment of patients, 58 Access to care barriers to, 150-157, 177 certificate of need and, 10, 158-163 defined, 335 dialysis patients, 135-164 donor organ supply and, 179-182 education/information and, 150-152 elderly patients, 150, 175 exclusion of individuals for medical reasons, 178 geographic variation in, 138-140, 160-162 and ineligibility for Medicare benefits, 6-7, 136-148 insurance coverage (private) and, 152-154, 172-173, 177-178, 330 magnitude of problem, 138 Medicare-eligible patients, 148-157 and payment sources other than Medicare, 140-146, 177-178 pediatric patients, 115, 149-150, 175, 176 preventive services, 156-157 rehabilitation services, 155-156 state regulations and, 158-163 transplants, 7-8, 167-185, 187 transportation and, 154-155 Activities of daily living, 335, 284 Advance directives, 56, 59-60, 335 Age and acceptance for treatment, 8, 52-53 and diabetic kidney disease, 90, 93 and employment of ESRD patients, 155 ESRD patient trends, 27, 64, 65, 67-68, 70, 91, 100, 150, 216 and health insurance coverage, 152 and hypertension, 95 and hypertensive ESRD, 90, 95-98 and mortality rates, 72, 74, 76-78, 213 and treatment modality, 91, 92, 168 and transplants, 168, 175, 176 see also Elderly patients; Pediatric patients Agency for Health Care Policy and Research, QA responsibilities, 276, 287-288 AIDS, 53, 178, 179-180, 184, 252, 286 Albuminuria screening, 94 Alternative Reimbursement Method, 202-203 American Diabetes Association, 94-95 American Medical Association, 202 American Outpatient Services Corporation, 129

OCR for page 411
Kidney Failure and the Federal Government American Society of Artificial Internal Organs, 329 American Society of Nephrology, 329 American Society of Transplant Surgeons, 316 Anemia clinical indicators of outcomes and process, 19, 281, 307-308 in pediatric patients, 86, 88 treatment of, 14, 25, 201, 226, 293-294, 305-308 see also Erythropoietin Antihypertensives, 88, 142-143 Arkansas, Medicare eligibility status of ESRD patients, 138-139 Asians/Pacific Islanders with ESRD gender differences in, 101 incidence and prevalence, 66-67, 70, 100, 103 Association for the Advancement of Medical Instrumentation, 228 Atherosclerotic disease, 53, 79, 80 B Baxter Healthcare, 329 Baxter Laboratories, 229 Blacks with ESRD diabetic, 93, 102 health insurance coverage, 152 hypertensive, 97, 102 incidence and prevalence, 5, 66-68, 70, 85-86, 99-100, 103, 156 mortality rates, 74, 76, 78, 105 pediatric patients, 85-86, 115 preventive care for, 156 primary diagnosis, 68-69 transplant rejection, 104 treatment modalities, 104, 175, 176-177, 183 see also Race/ethnicity Blood pressure, and renal disease, 99 Bone abnormalities, 86, 87-88, 149 C Calcium/phosphorus metabolism controllers, 143 Cancer, 53, 79, 80 Cardiac disease, 53 Carpal tunnel syndrome, 319 Case mix and composite rate, 252-253 defined, 336 in quality-of-life studies, 283, 284-285, 294-296, 319 reimbursement rate-setting and, 252-253, 284, 290 Catastrophic Health Insurance Act of 1988, 172 Catheter declotting, 238 Center hemodialysis, mortality rates, 77 Centers for Disease Control, QA responsibilities, 228, 276, 286 Cerebrovascular disease, 53, 79, 80 Certificate of need and access to care, 10, 158-163 constraints on providers, 114 defined, 336 elimination of, 160 survey of programs, 26 Chronic heart insufficiency, 80 Chronic pulmonary disease, 53, 79, 80 Cirrhosis, 80 Clinishare, 129 Community Psychiatric Centers, 129 Comorbidities, 11, 205 and acceptance for treatment, 8, 53 defined, 337 in diabetic ESRD, 94, 97 in elderly patients, 90, 91 in measures of quality, 280 and mortality rates, 72, 80, 94 in pediatric populations, 86 and quality of life, 8 severity assessment, 285 Composite rate 1983 ESRD, 12, 213-217, 220, 243, 253 1986 reduction proposal, 243-244 audited costs contrasted with, 245-246 and case mix, 252-253 covered outpatient services, 15-16, 29, 193, 236-240 derivation of, 196-199; see also Rate-setting process dual, 249-251, 253

OCR for page 411
Kidney Failure and the Federal Government exceptions and exemptions, 252-253 home dialysis supplies reimbursement, 25, 229 inflation/market basket adjustments, 252, 271 and innovation, 228, 253 labor portion on, 254-255 and mortality, 12 and patient morbidity, 217 and quality of care, 213-217 rebasing and updating, 251-254 reported costs contrasted with, 247-248 and unit staffing levels and composition, 220-221 see also Reimbursement Conditions of coverage for ESRD providers, 18, 288-290 Congressional charge to IOM, 3-4, 23-24, 62, 133, 212, 274 Connecticut, 158-162 Continuity of care concerns of patients, 42-43 for problem patients, 57, 58 Continuous ambulatory peritoneal dialysis, 162, 199, 228-229, 279, 283, 284, 309, 319, 337 Continuous cycling peritoneal dialysis, 201, 337 Continuous quality improvement, 19, 276, 297-300 Corticosteroid therapy, 88 Counseling, 46, 239 Cox proportional hazards model, 74, 319 Cox regression model, 77 Criteria screens, 253 Cushingoid facies, 88 Cyclosporine, 14, 143, 170, 172, 226, 230 D Data systems artifacts of, 73 National End-Stage Renal Disease Registry, 21, 25, 296, 321-324 needs, 20, 230 provider, 309-311 see also Health Care Financing Administration; Program Management and Medical Information System; United Network for Organ Sharing; United States Renal Data System Dementia, 53 Demonstration project, 25, 155, 201 Department of Veterans Affairs, 29 data reported to HCFA, 318 dialysis program, 6, 63, 65, 139, 140, 146 ESRD expenditures, 33, 147, 148 financial problems of patients, 136 research in dialysis, 329 Diabetes mellitus, 5, 12, 102, 338 Diabetic ESRD patients, 28, 29 age differences, 90, 93 albuminuria screening, 94 comorbidities, 94, 97 employment of, 155-156 gender differences, 68-70, 93 incidence and prevalence of ESRD, 29, 52, 63, 65, 66-68, 70, 93, 106 insulin-dependent, 93 mortality rates, 74-76, 78, 79, 81, 92, 94 non-insulin-dependent, 93-94, 101, 102 prevention, 94 protein intake, 94-95 quality of life, 283 racial differences, 68-70, 93-94, 102 risk factors, 94 transplants, 168 treatment of, 92-93 Diagnosis-related groups, 268, 270 Dialysis access problems, 135-164 and anemia, 14, 25, 201, 226, 293-294, 305-308 appropriateness of, 53 backup, 251, 259, 336 characteristics of patients, 52 costs of, 6, 14, 29, 135, 168, 226, 228, 254-255 covered services/allowable costs, 237, 242, 256 defined, 338 demand for, 10

OCR for page 411
Kidney Failure and the Federal Government elements involved in use of, 278-279 equipment and supplies, 45, 226-229, 244, 252, 253, 286-287 high flux, 45, 227, 253 hostile, abusive patients, 9, 58 infection control program, 286, 287 innovations, 45, 226-229 mortality rates, 82, 87, 105 noncompliant, self-destructive patients, 9, 57-58 patient population increases, 111 prescription, 253, 311 price level and hospitalization rates and length of stay, 13 processes of care, 277-278 reimbursement rate-setting, 27 reuse of equipment and supplies, 45 self-care, 289, 345 state programs, 144 technicians, 13, 43, 161, 218-220, 222, 223, 230, 277, 290 treatment times, 12-14, 214, 215, 217, 227, 230, 232, 244, 311 withdrawal from, 53 see also Hemodialysis; Inpatient dialysis; Outpatient dialysis; Peritoneal dialysis Dialysis Clinic, Inc., 129, 152, 178, 216, 218, 224-225, 300, 309-310 Dialysis Management, Inc., 126 Dialysis treatment facilities capacity, 10, 158-159 conditions of coverage, 288-289 cost reduction measures, 244-245 cost report data, 241 defined, 33-339 for-profit, 111 HCFA state surveys of, 19 number of Medicare-certified, 111 patient concerns about, 43 pediatric, 112 purchase prices of, 130 QA considerations and examples, 299-300, 309-311 response to economic constraints, 215-216, 225 rural, 112 staffing in, 13, 14, 43, 218-226, 230, 244-245, 290 stations/size, 111, 158, 339 utilization, 158-159 see also Outpatient dialysis Dialyzers, 226-227, 228, 244, 252 Dietitians, 13, 219, 220-222, 225, 230, 277, 290 Do Not Resuscitate status, 56 Durable power of attorney for health care, 56, 57, 339 E Education and training and access to care, 150-152 of dialysis technicians, 223, 287 and employment of ESRD patients, 155 for organ donation, 143 of patients, 41, 44-46, 50, 150-152, 289 QA-related, 287 Elderly ESRD patients access to care, 150, 175 causes of death, 92 comorbidities, 90, 91 growth in number of, 27, 29, 56-57, 89-90, 92, 106 incidence and prevalence of ESRD, 63, 90 mortality rates, 91 primary diagnosis, 90 treatment modality, 91, 92, 150, 175 see also Age Employment, barriers to, 48-49, 50, 155-156, 171, 173 End-stage renal disease (ESRD) causes of, 5 defined, 339 economic effects of, 47-49, 50, 330 patient experiences with, 40-47 race and, 5 End-stage renal disease patients acceptance criteria, 8, 52-55, 63, 66 age trends, 27, 64, 65, 67-68, 70, 91, 100, 150, 216 autonomy model of rights, 41 choice of provider, 10, 162 complexity (case mix), 252-253 composition of population, 5-6, 12,

OCR for page 411
Kidney Failure and the Federal Government 26, 27-28, 51-52, 65-69, 168, 174-178, 216, 256 conformance with treatment, 41, 42, 57-58, 80 counseling and self-help groups, 46 data sources and data files on, 317 education of, 41, 44-46, 50 effects of erythropoietin, 47, 50 employment problems, 48-49 experiences with renal failure, 40-47 family issues, 44 financial concerns and problems, 44, 47-49, 50, 150 incidence and prevalence of, 3, 5, 27, 30, 62-65, 70, 82 ineligible for Medicare benefits, 6, 7, 136-148 informed consent, 41 participation in care, 39, 276-277 by primary diagnosis, 64, 67-70 projections, 27-28, 30, 63, 66, 81-83, 90, 256 quality-of-life ratings, 8, 54 relationships with physicians and staff, 40-44, 49-50, 57-58, 151, 282 services important to, 46 types raising problems for providers, 9 see also Elderly ESRD patients; Focus groups; Pediatric ESRD patients End-Stage Renal Disease program cost control, 6 entitlement under Medicare, 3, 4, 7, 23, 35, 89, 135, 137 expenditures, 26, 28-33 growth of, 31, 65 management of, 4, 24 mortality in, 11-12, 69, 71-72 networks, 19, 24-25, 55-56, 276, 288, 291-293, 296-297, 319, 339 policy concerns, 4, 24, 39 services covered, 29, 32 success of, 3, 23 End-stage renal disease treatment acceptance criteria, 8 access to, 6-8, 24, 51 conformance with, 41, 57-58 cost-effectiveness studies, 21 costs of, 5-6, 19, 243-244 duration and outcomes, 12-13, 214, 215, 217 initiation of, 8-9, 53-54 limited-treatment plans, 56 modalities, see Dialysis; Transplants/transplantation; Treatment modality quality of care, 19; see also Quality assessment and assurance racial differences in, 103-104 technology, 26; see also Innovations and technical change time-limited trials, 56 withdrawal from, 9, 53-54, 55-57, 91 Epidemiology of kidney disease, 339 hypertensive, 96-98 diabetes, 63, 65, 66-68, 70, 93, 106 elderly, 63, 90 pediatric, 85-86 projections, 63, 66, 81-83, 90 research efforts, 20-21 see also Mortality Erythropoietin, 281 dosage calculations, 45, 294 clinical trials, 282, 294, 306 costs of, 201-202 effects of, 47, 50, 156, 306-307 injections per year, 239-240 purpose of, 14, 25, 226 and quality of life, 283-284, 294, 307-308, 319, 320 reimbursement policy, 25, 142-143, 193, 196, 201-202, 230, 239-240, 293, 295, 323 self-administration of, 25, 294 Ethical issues access to treatment, 51 facility ownership by physicians, 129-130 initiation of treatment, 8-9, 53-54 patient acceptance criteria, 8, 52-55 problem patients, 41, 57-58 transplants, 168 withdrawal from treatment, 9, 53-54, 55-57 Europe, survival of diabetic ESRD patients, 81 European Dialysis and Transplant Association, 79-80, 149-150

OCR for page 411
Kidney Failure and the Federal Government F First-difference model, 12, 213-214 Focus groups, 26-27, 151 composition of, 39-40, 409-410 objective of, 39-40 see also End-stage renal disease patients Food and Drug Administration, QA responsibilities, 229, 276, 286-287 G Gastrointestinal disease, 80 Gender and diabetic kidney disease, 68-70, 93 and employment of ESRD patients, 155 and hypertension, 95 and hypertensive ESRD, 68-70, 95-98 incidence and prevalence of ESRD, 66-70, 85, 101 and mortality rates, 74, 76 and transplants, 175, 176 Glomerulonephritis, 5 Glomerulonephritic ESRD, 5 gender differences, 69-70 incidence and prevalence of, 67, 68, 70 mortality rates, 75, 94 racial differences, 69-70, 102 Greenfield Health Systems Corporation, 129, 300, 310 Growth retardation, 86, 87, 88, 149 H Health Care Financing Administration (HCFA) administration of, 315 annual report on ESRD program, 316-317 Bureau of Data Management and Strategy, 293, 295, 315, 317 Bureau of Policy Development, 19, 293-294, 295 conditions of coverage for ESRD providers, 18, 288-290 coordination within, 295-296 cost data, 240-244, 271, 295 data acquisition, analysis, and systems, 20, 69, 71, 231, 315-318; see also Program Management and Medical Information System Health Standards and Quality Bureau, 19, 151, 288, 291-293, 295 Office of Research and Demonstrations, 19, 293, 294-295, 295, 317 patient survival data, 69 position on social service requirements, 224 QA responsibilities, 11, 19, 276, 288-297 state surveys of dialysis facilities, 19, 110, 276, 288, 290-291, 316, 318 Health insurance (private) and access to care, 152-154, 172-173, 177-178, 330 payment and/or qualification for, 48, 50, 154, 172-173 state payments into, 143 use by Medicare ineligibles, 136 Health Omnibus Programs Extension of 1988, 173 Health Systems Management, 129 Hemodialysis defined, 340 home, 25 innovations in, 226-228 patient distribution, 5 see also Dialysis Hemodialysis, Inc., 129 Hepatitis, 286, 305 Hirsutism, 88 Hispanics with ESRD, 5 access to care, 157 diabetics, 93 gender differences in, 101 incidence and prevalence of, 99, 100, 102 non-Medicare dialysis patients, 139 Home hemodialysis age and, 91 defined, 340 EPO administration, 202 paid aides for, 25 and quality of life, 283, 284 race and, 104 reimbursement for, 25, 196, 199, 200-201, 202-203, 229

OCR for page 411
Kidney Failure and the Federal Government relationships with providers, 40 training, 196, 309 Home Intensive Care, Inc., 25, 129, 200-201 Hospital Corporation of America, 298 Hospitals backup dialysis units, 251, 259, 336 organ donation protocols, 182 outpatient dialysis, 116-117, 119-121, 124, 125, 127, 128, 131, 159, 160 reimbursement of, 13, 29, 205-209 Hospitalization of dialysis patients reimbursement effects on, 216 -217, 230 reimbursement for, 12-13, 205-209 treatment time and, 217 trends, 319 Hypercreatinemia, 99 Hyperlipidemia, 99 Hyperphosphatemia, 310 Hypertension, 5 age and, 95 defined, 95, 340 erythropoietin and, 307 relationship to hypertensive ESRD, 96 in United States, 95-96 Hypertension Detection and Follow-up Program, 98-99 Hypertensive cardiomegaly, 80 Hypertensive ESRD age differences, 90, 95-98 and diabetic nephropathy, 94, 97 epidemiology of, 96-98 gender differences, 68-70, 95-98 incidence and prevalence of, 65-68, 70, 95-98, 106, 157 interventions, 98-99 mortality rates, 75-76, 78, 94, 96 racial differences, 68-70, 95-98, 101, 102 relationship to hypertension, 96 I Illinois, Medicare eligibility status of ESRD patients, 138-139, 141 Immunosuppressive drugs, 168 Medicare eligibility limitations, 4, 7, 24, 171-172, 174 patient concerns about, 45 reimbursement for, 193 side-effects in pediatric patients, 88 see also Cyclosporine; Imuran Imuran, 143 Indian Health Service, 6, 103-104, 140, 143, 146, 147 Infection control program, 286 Informed consent, 41, 150 Innovations and technical change clinical, 14 and composite rate, 253 dialysis research support, 229-220 equipment and supplies, 14, 226-228 hemodialysis, 226-228 labor substitution opportunities, 225 peritoneal dialysis, 228-229 reimbursement and, 13-14, 226-231 Inpatient dialysis, 29 age and, 91 benefit payments, 32, 206 capacity limits, 162 hospital reimbursement, 205-207 physician reimbursement, 208-209 and quality of life, 283, 284 race and, 103, 104 reimbursement for, 205-209 J Japan, ESRD mortality data, 79-80, 81 Joint Commission on Accreditation of Healthcare Organizations, 276 K Kentucky Organ Donation Agency, 179 Kidney Care, 129 Kidney failure, see End-stage renal disease Kidneys acquisition costs, 191-192 supply of donors, 8, 87, 178-182 L Licensed practical nurses, 13, 218-220, 290 Limited-treatment plans, 56 Living wills, 56, 57, 340

OCR for page 411
Kidney Failure and the Federal Government M Maryland, Medicare eligibility status of ESRD patients, 138-139 Medicaid, see State Medicaid programs Medical Case Review Procedures, 19, 292 Medical Device Amendments of 1976, 286 Medical Outcomes Study, 277, 278, 282, 285 Medical records review, 292-293 Medical review boards, 291-292 Medical Treatment Effectiveness Program, 288 Medicare Automated Data Retrieval System, 35 conditions of participation, 150, 182 copayments, 140, 142, 144 cost data timeliness, 240-241, 271 data sources and data files of ESRD patients and providers, 317 data systems adequacy, 324-325 defined, 341 eligibility for ESRD program, 3, 4, 7, 23, 149, 166, 339 ESRD QA function, 18, 19 expenditures for ESRD beneficiaries, 6, 28-33, 166, 168 expenses not covered by, 152 Fee Schedule, 18, 204, 255-256, 259 Hospital Insurance Trust Fund, 148 Part A Cost Principles, 241-242, 247, 342 recertification based on organ donor standard, 182 as secondary payer, 153-154, 193, 215, 260, 330 Supplemental Medical Insurance Trust Fund, 148 Medications, 143, 144 injections per year, 239-240, 254 reimbursement for, 25, 142-143, 193, 196, 201-202, 239 transplant-related, 144, 168, 170, 171-172, 174; see also Immuno-suppressive drugs see also specific drugs Mexican Americans, 102, 157 Michigan Kidney Registry, 77, 143 Minnesota Regional Kidney Disease Program, 77, 79, 80, 129 Minority patients, see Race/ethnicity; and specific minorities Models/modeling Bailey-Makeham, 391 continuous quality improvement, 297-300 Cox, 74, 77, 319, 386-388 exponential, 390 first-difference, 12, 213-214 logistic regression for probability of death, 388-391 parametric, 390-391 Poisson regression for death rates, 383-386 prescription dialysis, 253 price-level, 12, 13, 213-214, 217 regression models, 381-386 reimbursement effects, 12, 13, 213-214, 217 statistical methods for ESRD mortality data, 383-389 survival analysis, 372-373 Weibull, 390-391 Monthly capitation payment, 18, 202-204, 208, 255-256, 259, 341 Morbidity defined, 341-342 and dialysis treatment time, 14 measures of, 12-13 as outcome measure, 279 see also Hospitalization Mortality adjusted, 74, 75, 91, 94, 212 age and, 72, 74, 76-78, 213 analyses, 71, 295-296, 330-331; see also Statistical methods for ESRD mortality data; Survival analysis defined, 342 and dialysis treatment times, 12, 14 in ESRD program, 11-12, 69, 71-72 factors causing changes in, 71, 72, 80 international comparisons, 79-81, 395-399 as outcome measure, 12, 214-216, 279, 294 private insurance and, 152 and reimbursement rates, 12, 14, 212-216, 230

OCR for page 411
Kidney Failure and the Federal Government source of data, 69 state and regional data, 77, 79 subgroup, 74-78, 88, 91, 94, 103-104 transplants, 75, 77, 82, 87 treatment modality and, 104, 320 treatment time and, 12-13, 214, 215, 221, 222 trend analyses, 21, 71, 319 unadjusted, 72-74, 79, 212 Multivitamin compounds, 143 N Navajo Indians, 101 National Center for Health Services Research, 288 National End-Stage Renal Disease Registry, 21, 25, 296, 321-324, 318 National Health and Nutrition Examination Survey (II), 95, 102 National Institute of Allergy and Infectious Diseases, 287 National Institute of Diabetes and Digestive and Kidney Diseases, 20-21, 229, 285, 287, 296, 318-323, 330 Artificial Kidney/Chronic Uremia program, 227, 229, 287, 329 National Institutes of Health QA responsibilities, 287 National Kidney and Urologic Diseases Advisory Board, 328-329 National Kidney Foundation, Council of Nephrology Social Workers, 223-224 National Medical Care, Inc., 126, 129, 300, 310-311 National Medical Enterprises-Medical Ambulatory Care, 129 National Medical Review Criteria Screens, 19, 292 National Organ Transplant Act of 1986, 9, 25, 111, 170-171, 173, 182, 320 National Task Force on Organ Transplantation, 173, 175 Native Americans with ESRD gender differences, 101 incidence and prevalence of, 66-67, 70, 99-100, 103 non-Medicare dialysis patients, 139, 143, 146 outcomes research, 321 primary diagnosis, 68, 93, 101 see also specific tribes Neomedica Dialysis Centers, Inc., 129 Neurologic impairment, 53, 86, 88 New Mexico, Medicare eligibility status of ESRD patients, 138-139 New West Dialysis, 129 North American Pediatric Renal Transplant Cooperative Study, 149 North Central Dialysis Centers, 218-219, 220 Northwest Kidney Center, 129 Nursing/nurses assistants, 13, 218-219 quality assurance by, 277, 282 reimbursement effects on, 222-223, 230 requirements limiting capacity, 161 shortages, 43 staffing of dialysis units, 218-223 standards for, 289-290 Nutrition, parenteral, 238 O Obesity, 88 Omnibus Budget Reconciliation Act of 1981, 193, 195, 215, 233, 249 Omnibus Budget Reconciliation Act of 1985, 291 Omnibus Budget Reconciliation Act of 1986 data collection and analysis mandate, 21, 25, 296, 318, 321-323 ESRD network reorganization, 24-25, 291-292 quality and appropriateness of patient care, 19 reimbursement policy, 197, 201, 231-232, 251 transplant provisions, 172, 173 Omnibus Budget Reconciliation Act of 1987 charge to IOM, 3-4, 23-24, 133, 135, 212, 274, 283 composite dialysis rates, 251

OCR for page 411
Kidney Failure and the Federal Government Omnibus Budget Reconciliation Act of 1989 creation of AHCPR, 287-288 reimbursement policy, 25, 199, 204, 251 Omnibus Budget Reconciliation Act of 1990 advance directives, 59 demonstration project, 155, 201 EPO policy, 202 OPO performance standards, 182 reimbursement policy, 25, 153, 193, 198-199 research directives, 244, 260 Organ donation, 143, 184, 191-192 and access to care, 179-182 Organ Procurement and Transplantation Network, 25, 171, 174, 182, 320 Organ procurement organizations, 9, 111, 114 consolidation of, 174, 182 grant assistance to, 173 hospital-based, 111, 114 independent, 111, 114 reimbursement of, 192 staffing considerations, 183 Outcomes defined, 342 measures, 12, 19, 216, 279-280, 294, 307; see also Morbidity; Mortality and QA, 276-277, 279-280, 294 reimbursement and, 247, 249 research, 288 of transplants, 5, 167, 168, 170, 172, 174, 176 Outpatient dialysis advance directives legislation applied to, 59-60 chains, 126, 129, 131, 243, 258 cost report audits, 241, 245-246, 262-267 costs per treatment, 249-250, 296 covered services, 15-16, 29, 236-240 expenditures for, 29, 32, 206 facilities, 10, 112-114, 116-118, 119-122, 130, 193-202, 244-255 for-profit, 120-124, 126-129 hospital backup units, 251 hospital-based providers, 116-117, 119-121, 124, 125, 127, 128, 131, 159, 160, 195, 196, 218, 221-222, 245-250, 257 independent providers, 117-119, 121, 124, 126-128, 131, 159, 160, 195, 196, 198, 218, 220-222, 245-250 not-for-profit providers, 119-124, 127-129 ownership of facilities, 126, 129-130, 251, 257 patient numbers, 116-117, 118-119, 120-122, 125 physician reimbursement, 202-205, 255-256 rate-setting process, 240-244 reimbursement for, 6, 11, 13, 15-18, 193-205, 236-260 sampling of units, 241 stations/size, 116-118, 120-129, 131 structural changes in provider community, 116-130 treatment capacity, 10, 124 utilization rate, 116-117, 118-119, 131, 159-160, 162 see also Home hemodialysis P Parathyroid gland overactivity, 88 Patient characteristics, 277, 285 complexity, 284-285, 290, 296 functional and health status, 279-283, 284 satisfaction, 279, 280, 283 see also End-stage renal disease patients Pediatric ESRD patients, 59 access to care, 115, 149-150, 175, 176 acne, 88 anemia in, 86, 88 characteristics of population, 85-86 clinical trials of pharmaceuticals, 89 comorbidities, 86 facilities for, 112, 115-116 health status assessment, 282 incidence and prevalence of, 85-86 ineligible for Medicare, 149

OCR for page 411
Kidney Failure and the Federal Government mortality rates, 87, 88 pubertal development delays, 86, 88 quality-of-life factors, 86, 149, 150 special problems and needs of, 85, 88-89, 106, 149-150, 251, 253, 259, 319 transplantation in, 86-87, 149, 175, 176 Peripheral vascular disease, 53, 79, 80 Peritoneal dialysis, 29, 343 age and, 91 innovations in, 228-229 patient distribution, 5 race and, 104 Peritonitis, 319 Persistent vegetative state, 53 Physicians and other health care professionals characteristics, 277 education about ethical issues, 56 education of patients, 44-45, 151 monthly capitation payment, 18, 202-204, 208, 255-256, 259, 341 ownership of treatment facilities, 129-130, 257 pediatric specialists, 89 quality assurance by, 276 reimbursement of, 192-193, 202-204, 208-209, 255-256 relationships with patients, 40-44, 49-50, 57-58, 151, 282 supplier services, 29 training of, 43, 150 Pima Indians, 94, 101, 104 Poisson regression, 74 Polycystic disease, 75 Prescription drugs, see Medications; and specific drugs President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 53 Prevention of ESRD, 156-157, 329-330 Price-level model, 12, 13, 213-214, 217 Primary diagnosis of ESRD among blacks, 68-69 distribution of patients by, 64, 67-70 among elderly patients, 90 among Native Americans, 68, 93, 101 survival analysis and, 364-365 see also Diabetic ESRD patients; Glomerulonephritic ESRD patients; Hypertensive ESRD patients Processes of care, 19, 277-279, 281, 307-308 Professional Standards Review Organizations, 276, 288, 343 Program Management and Medical Information System, 62, 296, 315-318, 343 Prospective Payment Assessment Commission, 17, 18, 344, 241, 244 rate updating, 251, 258, 259, 260 Prospective Payment System, 215, 237, 343-344 inpatient hospital, 193-194, 205 Providers capacity of, 113, 114 certificate-of-need constraints on, 114 chains, 126, 129, 131, 243, 257, 310-311 characteristics, 277 conditions of coverage, 18 data sources and data files on, 317 demand for, 113 defined, 131 kidney transplant centers, 114-115 outpatient dialysis facilities, 10, 112-114 patient choice of, 10, 162 pediatric facilities, 115-116 response to economic constraints, 215-216 size of facilities, 113, 114, 115 staff/patient ratios, 43 structural changes in community, 9-10, 110-131, 116-130, 242 utilization of, 113 see also Dialysis treatment units; Outpatient dialysis Proximate clinical indicators, 279, 280-281, 305-308 Public Health Service Bureau of Quality Assurance, 315 dialysis patients, 65 Health Resources and Services Administration, 174, 184, 330 QA responsibilities, 276, 286-288

OCR for page 411
Kidney Failure and the Federal Government Public Health Service Act, 25, 171 Public hearings, 26-27, 218, 226, 242, 244, 245, 403-404 Q Quality assessment and assurance (QA) case mix and severity adjustments, 283, 284-285, 294-296, 319 conditions of coverage for ESRD providers, 18, 288-290 continuous quality improvement, 19, 276, 297-300 data needs, 296-297 defined, 344 in dialyzer reuse, 228 elements of ESRD QA function within Medicare, 18 examples of, 299-300, 309-311 federal responsibilities for, 276, 285-297; see also specific agencies and authorities functional-and health-status assessments, 281-283, 284, 294-295, 330-331 HCFA efforts, 11, 19 infection control program, 286 internal systems, 276 Medical Case Review Procedures, 19 medical review boards, 291-292 National Medical Review Criteria Screens, 19 obstacles, 274-275 outcomes and, 275, 279-280 patient satisfaction and, 283 principles of, 275-277 process of care and, 277-279, 280 proximate clinical indicators, 280-281, 305-308 purposes of, 275-276 quality of life and, 283-284 and rate-setting, 258 state surveys of dialysis facilities, 19, 110, 290-291 structure and, 277, 280 Quality of care, 17 certificate of need and, 10, 162 composite rate and, 213-217 cost of treatment and, 19, 244 defined, 275, 344 measures of, 12-13, 19, 218, 279-280, 288 and provider community structure, 130-131, 257 reimbursement and, 11-18, 212-233, 256-257, 268-269, 272 standards of care, 237-238, 268-269, 280 treatment time and, 221 treatment unit staffing and, 43, 218-225 Quality of life comorbidities and, 8 erythropoietin and, 283-284, 294, 307-308, 319 life-sustaining treatment and, 53 measures of, 54, 283-284 patient rating of, 8, 54 of pediatric patients, 86, 149 research, 294 R Race/ethnicity and age of ESRD patients, 100 and diabetic ESRD, 68-70, 93-94, 101, 102 and eligibility for Medicare ESRD program, 139-140 and ESRD incidence and prevalence, 5, 66-70, 85-86, 93, 99-103, 106, 157, 319 and glomerulonephritic ESRD, 101, 102 and hypertension, 95 and hypertensive ESRD, 68-70, 95-98, 101, 102 and mortality rates, 103-104 and primary diagnosis leading to ESRD, 67-70, 101 and risk of ESRD, 99 and treatment modality, 103-105, 176-177 see also Asian Americans; Blacks; Hispanics; Native Americans Rate-setting process conflicts between HCFA and ESRD providers in, 243

OCR for page 411
Kidney Failure and the Federal Government cost data timeliness, 240-244, 271 cost-per-treatment calculation, 243-244 defined, 344 dissenting view of, 268-273 generally accepted accounting principles in, 242 goals of, 236 Medicare Part A cost principles in, 241-243, 247, 256 oversight of, 244, 258 procedural issues, 243 public hearings on, 27, 242, 244, 245 and quality assessment and assurance, 251, 258, 290 sampling versus universe, 241, 262-267 Recommendations access to treatment, 4, 7-8, 24 advance directives, 59 advisory group of nephrology professionals and experts, 20, 301 certificate of need, 11, 162-163 composite rate, 258-259 continuing education in medical ethics and health law, 9, 59 data systems, 19, 20-21, 301, 325-326 entitlement to ESRD treatment, 4, 7, 89, 148 funding considerations, 3, 24, 173 HCFA state survey system, 19, 301 kidney donation, 8, 183, 184, 326 immunosuppressive drug coverage, 8, 173 initiation of treatment, 9, 59 management of ESRD program, 4, 24 Medicare secondary-payer provision, 154 monitoring organizational changes in provider community, 10, 131 National End-Stage Renal Disease Registry, 21, 326 patient acceptance criteria, 9, 59 patient education, 152 quality assurance and assessment, 19-20, 259, 301-302, 326 quality of care, 4, 24, 301 reimbursement policies for dialysis facilities, 17-18, 19, 257, 258 -259, 301 research, 20, 21-22, 59, 301 transplant eligibility limits, 7-8, 173 United States Renal Data System, 21, 326 withdrawal from treatment, 59 Registered nurses, 13, 218-223, 289 Regulations ESRD network medical review boards, 291-292 interim, of 1983, 227-228 see also Certificate of need; State regulations Rehabilitation barriers to, 50, 155-156 reimbursement for physical therapy, 239 Reimbursement and access to care, 161 Alternative Reimbursement Method, 202-203 appropriateness screens, 291 assessing the effects of, 12, 213, 214-215 case mix and, 252-253, 284, 290 and clinical research, 329 current policy, 198-199 exceptions and exemptions, 194, 199-200, 252-253 facility/center, 191-192, 192-202, 244-255 and hospitalization, 216-217, 230 of hospitals, 205, 207 historical overview, 193-198 home dialysis, 25, 196, 199, 200-201, 202-203, 229 and innovation, 13-14, 226-231, 256 inpatient dialysis services, 205-209 level-of-payment issues, 244-249 for medications, 25, 142-143, 193, 196, 201-202, 230, 239-240, 293 -295 monthly capitation payment, 202-204, 208 and mortality, 12, 14, 212-216, 230 from non-Medicare sources, 142, 153 outpatient dialysis, 6, 11, 13, 15-18, 193-205, 236-260

OCR for page 411
Kidney Failure and the Federal Government and patient characteristics, 207 of physicians, 192-192, 202-205, 208-209, 255-256 policy options, 16, 18 and quality of care, 11-18, 212-233, 247, 249, 256-257, 272 rebasing, 15-18, 194, 344 retrospective, cost-based, 242 staffing in treatment units and, 13, 14, 218-225, 230, 247, 290 transplant services, 191-193 see also Composite rate; Rate-setting process REN Corporation-USA, 129 Renal biopsy, 319 Renal Physicians Association, 323 Renal Treatment Centers Corporation, 129 Research basic, 20, 328 clinical, 20, 229, 282, 328, 329 dialysis, 229-230 epidemiologic, 21-22, 294, 296, 316, 318, 322-323, 330 on ethical issues, 59 health services, 22, 287-288, 324, 328, 331 mortality, 319, 330-331, 398-399 needs, 328-332, 398-399 outcomes and effectiveness, 288, 319, 321, 331 preventive, 20 treatment modality effectiveness, 284, 320, 329-330 S Salick Health Care, 129 San Antonio Heart Study, 157 Satellite Dialysis, 129 Self-help groups, 46 Sickness Impact Profile, 284, 307 Social Security Administration, Bureau of Health Insurance, 315 Social Security Amendments of 1972, 3, 6, 23, 133, 135, 170 Social Security Amendments of 1973, 137 Social Security Amendments of 1978, 195 Social Security disability regulations, 48, 50, 155, 171 Social workers, 13, 218-221, 222-225, 230, 290, 277 Southeast Organ Procurement Foundation, 174, 320 State kidney programs, 143-147 State Medicaid programs benefits of, 6-7, 142, 146, 155 defined, 341 dual eligibles, 142 expenditures for ESRD patients, 140, 142 reimbursement levels and policy, 142 use by ESRD patients, 136, 140, 148 State regulations, and access to care, 158-163 Statistical methods for ESRD mortality data Bailey-Makeham model, 391 comparative parameters, 380-383 Cox models for relative rates and survival functions, 386-388 death proportions, 376-377, 386-388 death rates, 377-379, 381-388, 393-394 descriptive parameters for one group, 376-380 expected lifetimes, 379-380 exponential model, 390 frailty, 392 institutional characteristics, 394 logistic regression for probability of death, 388-391 models and methods, 383-389 parametric models, 390-391 Poisson regression for death rates, 383-386 prevalent versus incident cohort analyses, 391-392 regression models, 381-386 sampling from risk set, 380-391 standardization (internal and external), 394-395 survival curves, 379, 382-383, 386-388 treatment modality, 393 Weibull model, 390-391

OCR for page 411
Kidney Failure and the Federal Government Survival analysis adjustment for patient characteristics, 364-375 age adjustments, 358-359, 365, 397-398 biased comparisons, 358-359 comparison group, 357 constraints on adjustment process, 374-375 counts of patients, accuracy of, 363-364 data currently available for, 364-367 data unavailable or difficult to evaluate, 368-370 diagnosis and, 364-365 error (types I and II) issues, 363 etiology in, 396-397 examples of, 356-364 inappropriate comparison group, 358-359 gender in, 367 general issues in, 355-364 international comparisons, 79-81, 395-399 limitations of, 395-398 medical history, 368-369 modeling, 372-373 multivariable methods, 370-374 overview of, 355-356 parameters for mortality summaries, choice of, 362-363 patient follow-up, 398 population identification, 356-357 projections and extrapolations, 363 provider versus patient, 361-362 race in, 367 random variation in, 360-361 research needs, 398-399 significant versus important differences, 361 social support systems, 369-370 spurious differences in, 358 standard errors for population data, 359-360 stratification, 371-372 time in multiple measures, 367 treatment methods, 365-366 treatment modality, 368 unobserved factors, 359 variables exerting simultaneous effects, 374 withdrawal rates, 398 year of first treatment, 365-366 years of treatment, 366-367 see also Mortality; Statistical methods for ESRD mortality data Swedish dialysis centers, 80 T Tax Equity and Fiscal Responsibility Act of 1982, 137, 345-346 Technicians, see Dialysis technicians Texas Kidney Health Program, 102, 143 Tidewater Nephrology Associates, 129 Time-limited trials, 56 Training, see Education and training Transplant Amendments Act of 1990, 173, 177, 184, 330 Transplant recipients access restrictions, 7-8, 167-185, 187 age and, 168, 175, 176 characteristics of patient population, 5, 26, 91, 168, 174-178 compliance with drug regimens, 172 employment of, 171, 173 mortality rates, 75, 77, 82, 87 outcomes, 5, 167, 168, 170, 172, 174, 176 pediatric, 86-87, 149, 175, 176 projections, 82 quality of life, 283, 284 racial differences in, 104-105, 176-177 rehabilitation services, 155 self-destructive, 9, 58 Transplants/transplantation access to kidneys, 26, 87, 150, 167, 170, 173-178 from cadaver donors, 5, 75, 77, 82, 87, 104, 105, 114, 168-170, 175, 176, 182, 336 conditions of coverage, 288-289 cost-effectiveness of, 168 costs of, 6, 29, 115, 135, 168, 192 covered services, 237

OCR for page 411
Kidney Failure and the Federal Government demand for kidneys, 8, 167, 170 distribution of, 173-178 facilities/centers, 9, 111, 114-115, 191-192, 346 follow-up care, 143, 151-152 HLA matching, 104, 174, 175, 176, 177, 179, 319, 321 legislation, 25, 170-171 from living related donors, 5, 82, 87, 168-170, 175, 176, 192, 340, 284 media coverage of, 181-182 Medicare benefit, 29, 170-173 Medicare eligibility limitations, 4, 5, 24, 171 medications, 144, 168, 170, 171-172, 174; see also Immunosuppressive drugs; and specific medications number of procedures, 5, 111, 114, 168-169, 171, 179 parent-child, 319 patient information about, 151 point scoring system, 176-177 registry, 173, 174, 192 reimbursement for, 191-193 rejection of grafts, 40, 88, 104, 105, 168, 284 state programs for, 144 supply of donor organs, 179-183 survival of grafts, 168, 170, 176 waiting lists, 40, 170, 171, 175-176, 192, 321 workup procedures, 143 Transportation and access to care, 154-155 financial assistance for, 143-144, 150 Treatment modality, 23, 44 age and, 91, 92, 168 distribution of patients by, 5 effectiveness research, 284, 320, 329-330 for elderly patients, 91, 92, 150, 175 and mortality, 104, 320, 368 race/ethnicity and, 103-105, 176-177 in statistical analyses, 368, 393 see also Dialysis; Transplants/ transplantation U United Network for Organ Sharing, 174, 320-321 United States Renal Data System, 20, 21, 25, 62, 296, 318-320 mortality analyses, 69, 71, 323 Scientific Advisory Committee, 285, 323 Utilization and Quality Control Peer Review Organizations, 276, 288 Urokinase, 238 V Vivra, Inc., 129 W W.R. Grace, Inc., 129 West Suburban Kidney Centers, 129 Z Zuni Indians, 102