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Abstract: TH-PO390

Impacts of Medicare Bundled Payment on Utilization of Peritoneal Dialysis and Changes in Treatment Modality

Session Information

Category: Dialysis

  • 703 Dialysis: Peritoneal Dialysis

Authors

  • Wang, Virginia, Duke Univ, Durham, North Carolina, United States
  • Coffman, Cynthia, Duke Univ, Durham, North Carolina, United States
  • Sanders, Linda L., Duke Univ, Durham, North Carolina, United States
  • Hirth, Richard A., U of Michigan, Ann Arbor, Michigan, United States
  • Lee, Shoou-Yih Daniel, U of Michigan, Ann Arbor, Michigan, United States
  • Sloan, Caroline E., Duke Univ, Durham, North Carolina, United States
  • Maciejewski, Matthew L., Duke Univ, Durham, North Carolina, United States
Background

In 2011, Medicare implemented a new policy that bundled reimbursement for dialysis treatment and ancillary services, removing incentives that made HD a more profitable therapy than PD under the prior payment model. This study examined whether 2011 Medicare ESRD bundled payment (BP) was associated with increased rates of PD utilization and modality switches.

Methods

We used USRDS and Medicare data to identify all US patients with ESRD initiating dialysis (n=619,130) and outpatient dialysis facilities (n=6,433) before (2006-2010) and after (2011-2013) BP. We used logistic models to examine the BP effect on two outcomes of interest observed 90 days after dialysis initiation up to 2 years: any patient utilization of PD and change in treatment modality (HD-PD and PD-HD), adjusting for patient, dialysis provider, and regional characteristics.

Results

Observed PD utilization increased from 12.5% in 2006, to 15.0% in 2010 (the year prior to policy change), and to 18.7% in 2013. In adjusted models, BP was associated with increases in PD use in the pre- vs. post-BP era (OR=1.6; 95% CI 1.5,1.6; p<0.0001) and an estimated BP effect of 5 percentage points in PD use between pre and post policy periods (14% pre vs 19% post, for fixed values of covariates).
Observed rates of modality switches increased from 6.1% in 2006, to 7.5% in 2010 and 9.0% in 2013. Of those initiating HD in the first 90 days, 4.7% switched to PD up to 2 years later in the pre-policy period and 6.3% in the post-policy period. Of those initiating PD in the first 90 days, 24.6% switched to HD in the pre-policy period and 24.1% in post-policy. In adjusted models, BP was associated with higher rates of modality switches for both PD-HD (OR=1.1 95% CI 1.0,1.1; p=0.009) and HD-PD (OR=1.4 95% CI 1.4,1.5; p<0.0001). There was an estimated 0.4 percentage point BP effect on PD-HD switches (18.0% pre vs 18.4% post) and 1.7 percentage points for HD-PD switches (4.4% pre vs 6.1% post).

Conclusion

ESRD bundled payment was associated with increased PD use without a substantial increase in modality failure, achieving a secondary goal of payment reform. More work is needed to determine whether increased use and HD-PD modality switches from payment reform also led to changes in patient characteristics associated with modality use.

Funding

  • NIDDK Support