VA Policies to Establish National Dialysis Contracts Reduce Reimbursement Without Compromising Access or Survival
BACKGROUND:
Due to limited capacity of VA dialysis facilities and the need for Veterans to receive treatment close to home, VA has a long history of reliance on community dialysis providers that predates recent legislation to promote access to community care for Veterans (e.g., 2014 VA Choice Act and 2018 VA MISSION Act). In 2013, VA introduced a national contracting mechanism for community dialysis with prices set slightly above Medicare rates. This study examined whether changes in VA reimbursement and contracting policies were associated with VA spending on dialysis, Veterans’ access to dialysis care, and mortality. Using VA, Medicare, and US Renal Data System data, investigators identified Veterans (n=24,870) who received VA-financed dialysis in community-based dialysis facilities before (2006-2008), during (2009-2010), and after the enactment of VA policies to standardize dialysis payments (2011-2016). Investigators then examined trends in the average reimbursement for community-based dialysis, access to quality care (Veteran distance to community dialysis, number of community dialysis providers, dialysis facility quality indicators), and one-year mortality.
FINDINGS:
- VA policies to standardize payment and establish national dialysis contracts increased the value of community dialysis care by reducing costs without compromising access to care or survival.
- Over the time period that payment reforms went into effect, there was an estimated 44% reduction in average treatment prices for VA-financed community-based dialysis care. Over the same time period, there was an increase in the number of community dialysis facilities contracting with VA to deliver care to Veterans with end-stage kidney disease from 19 to 37 facilities (per VAMC), and there were no changes in either the quality of community dialysis facilities or in the 1-year mortality rate of Veterans (12% vs. 11%).
IMPLICATIONS:
- Standardization of payments to community dialysis providers did not appear to have unintended adverse effects on access to care or mortality, suggesting that national price setting may be a feasible approach for VA to improve the value of community care more broadly.
LIMITATIONS:
- This study was not able to distinguish the impact of the Medicare prospective payment reform because Medicare bundled payments were established around the same time VA embarked on changes to standardize payments to community providers.
AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 15-301) and a Research Career Scientist award (RCS 10-391). Drs. Wang and Maciejewski are part of HSR&D’s Center of Innovation to Accelerate Discovery & Practice Transformation; Drs. Swaminathan, Trivedi, and Mor, and Ms. Corneau are part of HSR&D’s Center of Innovation for Long-Term Services and Supports. Dr. O’Hare is part of HSR&D’s Center of Innovation for Veteran-Centered and Value-Driven Care
Wang V, Swaminathan S, Corneau E, Maciejewski M, Trivedi A, O’Hare A, and Mor V. Association of VA Payment Reform for Dialysis with Spending, Access to Care, and Outcomes for Veterans with End-Stage Kidney Disease. Clinical Journal of the American Society of Nephrology. September 22, 2020; Epub ahead of print.
