Restructuring the ESRD payment system in the United States
2004; Elsevier BV; Volume: 66; Issue: 1 Linguagem: Inglês
10.1111/j.1523-1755.2004.00753.x
ISSN1523-1755
Autores Tópico(s)Primary Care and Health Outcomes
ResumoA 57-year-old African American woman with end-stage renal disease (ESRD) secondary to diabetes mellitus was enrolled in a managed care plan. Her primary care physician told her that he was monitoring her diabetes and there was no need for her to see other medical subspecialists. On presentation to the emergency room at the UCLA Medical Center, she reported that she used pork insulin one to two times daily but had not had her blood sugar checked in the past year. Medication had been prescribed for her hypertension, but she could not afford to buy it. She also noted that she was blind in her left eye and was gradually losing vision in her right eye. A referral to an ophthalmologist was pending. In the emergency room, she had physical findings consistent with anasarca. The serum creatinine was 8 mg/dL, blood sugar was 480 mg/dL, and hemoglobin was 9 g/dL. She was refractory to diuretic therapy, and dialysis was initiated through a temporary catheter to control excessive fluid and symptoms of uremia. Therapy with subcutaneous recombinant human erythropoietin (rHuEpo) was started and she was referred to a free-standing hemodialysis center, where she began thrice-weekly hemodialysis. She was stabilized on hemodialysis with slow removal of excess fluid and improvement of anemia with rHuEpo. She complained of pain at the site of injection of the Epo and was told that this was the most cost-effective way of administering the drug. Three months after dialysis was initiated, the hemoglobin A1c was 9.5%. The patient was instructed to follow up with her primary care physician for further evaluation, but she did not do so. Six months after starting dialysis, she complained of pain and numbness in her right foot and was told to discuss this with her primary care physician. Because she came to dialysis three times per week, however, and had to use public transportation, she was not able to follow up on this problem either. After one year on dialysis, she was told that her phosphorus level was too high, and that she needed to take a new form of phosphate binder, sevelamer. She was given a prescription for the sevelamer, but when she went to pick it up at the pharmacy, the cost was prohibitive, so she did not buy it. The following month, her laboratory studies showed a phosphorus of 10 mg/dL with a calcium of 9.5 mg/dL, and she was again encouraged to take the sevelamer. An ulcer was noted on her right ankle, and several toes on that foot were cold. Doppler flow studies showed severe large- and small-vessel disease, and radiographs disclosed diffuse vascular calcifications. She was admitted to the hospital for debridement of the ulcer, but shortly after admission she complained of severe substernal chest pain when she became hypotensive during an inpatient dialysis session. Dialysis was discontinued and intravenous saline was administered, but she developed ventricular fibrillation and could not be resuscitated. Dr. Allen R. Nissenson (Professor of Medicine, Director, Dialysis Program, Department of Medicine, Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, California): In the 30 years since patient entitlement to care for ESRD was enacted, the ESRD program has provided life-saving treatment to hundreds of thousands of patients. It has become clear recently, however, that the program faces significant challenges in the 21st century, including a growing population of patients of increasing medical complexity, a rapid rise in the overall costs of care, and the lack of access to integrated, coordinated care delivery systems1.Nissenson A.R. Rettig R.A. Medicare's end-stage renal disease program: current status and future prospects.Health Aff. 1999; 18: 161-179Crossref PubMed Scopus (40) Google Scholar. The Medicare entitlement for patients with ESRD came with the passing of an amendment to the Social Security Act in 1972 (section 299I of Public Law 92–603, 1972 Amendments to the Social Security Act), and its enactment in July 1973, establishing ESRD as the only health condition so covered under Medicare in the absence of age over 65 or other disability2.Hull A.R. The legislative and regulatory process in the end-stage renal disease (ESRD) program, 1973 through 1997.Semin Nephrol. 1997; 17: 160-169PubMed Google Scholar. It was envisioned that this program would be of great social value, restoring hope and productivity to the small group of individuals (approximately 7000 at the time) afflicted with this otherwise fatal condition. By 2001 this population had grown to more than 350,000, is currently growing at 7% per year, and is projected to double over the coming decade3.U.S. Renal Data SystemUSRDS 2003 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2003Google Scholar. In addition, the average age of ESRD patients has steadily risen, now approaching 60 years, and co-morbid conditions are common, including diabetes, hypertension, and cardiovascular disease. Once thought to be key to improving outcomes and lowering costs, home dialysis and kidney transplantation have been unable to fulfill these hopes, and in-center hemodialysis has prevailed as the dominant form of therapy. In 1991, the first year for which such data are available, the overall costs of caring for ESRD patients was $8 billion, nearly $6 billion of which was expended by Medicare3.U.S. Renal Data SystemUSRDS 2003 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2003Google Scholar. Despite making Medicare the “secondary payer” (that is, only responsible for up to 20% of Medicare-allowable costs not paid by the primary insurance) for the first 30 months of ESRD, thus placing a greater burden on private insurance plans (“the primary payer,” that is, responsible for paying the bulk of the cost of ESRD care) since 1997, total ESRD costs skyrocketed to nearly $23 billion in 2001, more than $15 billion of which came from Medicare Figure 1. This near tripling of the Medicare ESRD expenditures, which occurred while the overall Medicare budget merely doubled, represents 6.4% of the total Medicare payments, for coverage of less than 1% of the Medicare population. Of great concern is the absolute increase in expenditures for ESRD patients, representing both growth of the patient population and increasing patient complexity, as well as the rate of growth of direct expenses, with an 11.5% increase from 2000 to 2001. It should be noted that outpatient expenditures are growing at a much faster rate than inpatient and physician costs Figure 2, primarily because of the increasing use and cost of injectable medications, including erythropoietic-stimulating proteins, vitamin D, iron, and carnitine3.U.S. Renal Data SystemUSRDS 2003 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2003Google Scholar.Figure 2Medicare spending on injectable medications over the past decade.reproduced with permission from3.U.S. Renal Data SystemUSRDS 2003 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2003Google ScholarView Large Image Figure ViewerDownload (PPT) Many Medicare + Choice organizations (managed care health plans contracted with Medicare) and private insurers have realized the importance of the effective coordination of care for persons with chronic conditions4.Anderson G. Knickman J.R. Changing the chronic care system to meet people's needs.Health Aff. 2001; 20: 146-160Crossref PubMed Scopus (141) Google Scholar, 5.Wolff J.L. Starfield B. Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly.Arch Intern Med. 2002; 162: 2269-2276Crossref PubMed Scopus (1622) Google Scholar, 6.Capitman J. Effective coordination of medical and supportive services.J Aging Health. 2003; 15: 124-164Crossref PubMed Scopus (25) Google Scholar. Both the quality and cost of care can be improved through better integration of the delivery system7.Wagner E.H. Austin B.T. Davis C. et al.Improving chronic illness care: Translating evidence into action.Health Aff. 2001; 20: 64-78Crossref PubMed Scopus (2342) Google Scholar. Specifically, these organizations have utilized a wide array of tools ranging from disease management services and patient and provider education programs to innovative funding mechanisms and incentives for achieving tighter coordination of care within non-coordinated or fragmented provider communities8.Nissenson A.R. Collins A. Dickmeyer J. et al.Evaluation of disease-state management of dialysis patients.Am J Kidney Dis. 2001; 37: 938-944Abstract Full Text PDF PubMed Scopus (28) Google Scholar, 9.Nissenson A.R. Outcomes associated with a disease management program for end-state renal disease.Dis Man Health Outcomes. 2002; 10: 93-100Crossref Scopus (5) Google Scholar, 10.Nissenson A.R. Disease Management Improves Outcomes in Patients with CKD.Nephrology News Issues. 2003Google Scholar. Beneficiaries with ESRD, however, are the only group eligible for benefits under Medicare Part A (primarily pays for inpatient services) and B (pays for outpatient dialysis treatments and outpatient physician services) who are prohibited from enrolling in Medicare + Choice organizations, and thus from access to care-coordination programs. In addition, because Medicare does not reimburse for the costs of disease management services, this approach to care has not generally been possible for fee-for-service Medicare patients. Patients with chronic kidney disease (CKD) who are not yet on dialysis are not eligible for Medicare unless they are 65 years old or older or disabled. The issue of the cost of the ESRD program is not a new one. In the 1991 landmark report from the Institute of Medicine, nearly one-quarter of the publication addressed issues related to reimbursement11.Rettig R.A. Levinsky N.G. Kidney Failure and the Federal Government, National Academy Press, Washington, DC1991: 191-273Google Scholar. More recent publications provide analyses of financing the ESRD program as well1.Nissenson A.R. Rettig R.A. Medicare's end-stage renal disease program: current status and future prospects.Health Aff. 1999; 18: 161-179Crossref PubMed Scopus (40) Google Scholar, 12.Farley D.O. Financing of end-stage renal disease care: Past, present and future.Adv Ren Replace Ther. 1994; 1: 24-31PubMed Google Scholar, 13.Nissenson A.R. Daily hemodialysis: Challenges and opportunities in the delivery and financing of end-stage renal disease patient care.Adv Ren Replace Ther. 2001; 8: 286-292Abstract Full Text PDF PubMed Scopus (11) Google Scholar, 14.Bruns F.J. Seddon P. Saul M. Zeidel M.L. The cost of caring for end-stage kidney disease patients: an analysis based on hospital financial transaction records.J Am Soc Nephrol. 1998; 9: 884-890PubMed Google Scholar, 15.Ploth D.W. Shepp P.H. Counts C. Hutchison F. Prospective analysis of global costs for maintenance of patients with ESRD.Am J Kidney Dis. 2003; 42: 12-21Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 16.Ray N.F. Ross M. Challenges and directions for Medicare ESRD payment policy.Semin Nephrol. 2000; 20: 565-576PubMed Google Scholar. As expenditures for the care of ESRD patients have continued to escalate, and pressures on the Medicare system overall to constrain costs have increased, more and more stakeholder groups are focusing on the current payment system for ESRD, including government regulators, legislators, and renal community organizations (that is, professional and lay organizations). The current system is acknowledged to be replete with shortcomings and idiosyncrasies, and considerable momentum is building to have it restructured. Some of the specific factors that are driving this re-evaluation have been recently summarized by the Renal Physicians Association and American Society of Nephrology in a White Paper on this topic, including17.Renal Physicians Association/American Society of Nephrology: White Paper on the ESRD Payment System, document 3.02, July 20, 2002, http://www.renalmd.orgGoogle Scholar: “proposals from the dialysis industry and federal advisory bodies such as the Medicare Payment Advisory Commission (MedPAC) to revise the system18.Medicare Payment Advisory Commission: Report to the Congress: Medicare Payment Policy (March 2001), Washington, D.C.Google Scholar; continued reductions in physician payments for inpatient services; recommendations to stratify payments for ESRD services based on severity of illness and patient co-morbidities19.Beddhu S. Bruns F.J. Saul M. et al.A simple comorbidity scale predicts clinical outcomes and costs in dialysis patients.Am J Med. 2000; 108: 609-613Abstract Full Text Full Text PDF PubMed Scopus (392) Google Scholar,20.Chertow G.M. Leveling the “paying” field in end-stage renal disease.Am J Med. 2000; 108: 666-667Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar; multiple price increases for Epogen®; controversies over payment for other injectable drugs and separately billable services; the tenuous financial viability of independent dialysis facilities; the continued growth of ESRD patient participation in the Medicare + Choice system21.Eggers P.W. FrankenfieLD D.L. Greer J.W. McClellan W. Owen W.F. Rocco M.V. Comparison of mortality and intermediate outcomes between medicare dialysis patients in HMO and fee for service.Am J Kidney Dis. 2002; 39: 796-804Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar; the completion of the ESRD Global Capitation Demonstration Project22.Centers for Medicare and Medicaid Services: End stage renal disease (ESRD) program: ESRD managed care demonstration http://www.cms.hhs.gov/esrd/6.asp, accessed, 2003Google Scholar; pressure from the Office of the Inspector General (OIG) to examine and possibly reduce dialysis facility Medical Director compensation; recommendations from the Institute of Medicine regarding reimbursement changes to improve the quality of care for chronically ill patients, including the use of incentives based on quality outcomes23.Institute of Medicine: Crossing the Quality Chasm, Washington, D.C., National Academy Press, 2001, pp 193-219.Google Scholar; the improving longevity of ESRD patients, resulting in an aging of the ESRD population that often has multiple co-morbidities; the growing need for nephrologists to assume the role of primary care physician for patients with ESRD and those with CKD not yet on dialysis; and the greater need for nephrologists to identify and manage medical co-morbidities, including cardiovascular disease and diabetes6.Capitman J. Effective coordination of medical and supportive services.J Aging Health. 2003; 15: 124-164Crossref PubMed Scopus (25) Google Scholar, 7.Wagner E.H. Austin B.T. Davis C. et al.Improving chronic illness care: Translating evidence into action.Health Aff. 2001; 20: 64-78Crossref PubMed Scopus (2342) Google Scholar, 8.Nissenson A.R. Collins A. Dickmeyer J. et al.Evaluation of disease-state management of dialysis patients.Am J Kidney Dis. 2001; 37: 938-944Abstract Full Text PDF PubMed Scopus (28) Google Scholar, 24.Lowrie E.G. Teng M. Lacson E. et al.Association between prevalent care process measures and facility-specific mortality rates.Kidney Int. 2001; 60: 1917-1929Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar.” The Medicare program overall is experiencing increasing pressures to control costs and demonstrate value in the services provided to beneficiaries. It is projected that the total number of Medicare beneficiaries will nearly double by 2030, totaling nearly 80 million individuals. At present a significant number of Medicare patients have impaired functional status, and this number is expected to grow. Over one-half of Medicare beneficiaries report that they have hypertension, and nearly 20% have diabetes25.Medicare Payment Advisory Commission: Report to the Congress: Medicare Payment Policy (March 2003), Washington, D.C.Google Scholar. The United States currently spends over $1.24 trillion on health care. This amount represents over 12% of the United States gross domestic product, among the highest health care expenditures in the world26.Chernew M.E. Hirth R.A. Cutler D.M. Increased spending on health care: How much can the United States afford?.Health Aff. 2003; 22: 15-25Crossref PubMed Scopus (92) Google Scholar. One-fifth of total expenditures come from Medicare, which is the largest single purchaser of health care services. This spending is concentrated on a small number of beneficiaries, with 19% of individuals accounting for 85% of expenditures. This group includes patients with multiple chronic conditions and contains the vast majority of ESRD patients. In the early 1970s, Medicare approved payments of $150 per dialysis treatment. Medicare, of course, actually paid only 80% of this amount, not including payment to the physicians1.Nissenson A.R. Rettig R.A. Medicare's end-stage renal disease program: current status and future prospects.Health Aff. 1999; 18: 161-179Crossref PubMed Scopus (40) Google Scholar,12.Farley D.O. Financing of end-stage renal disease care: Past, present and future.Adv Ren Replace Ther. 1994; 1: 24-31PubMed Google Scholar. By the late 1970s, however, because of concerns over the increasing overall program costs and the declining interest in home dialysis, Congress passed legislation in an attempt to encourage the use of home dialysis and transplantation, and mandated the Department of Health and Human Services (DHHS) to develop a “prospective payment rate” for dialysis services. This approach was finally implemented in the fall of 1983. One feature of the new rate was a differential payment ($4 higher on average) to hospital-based facilities compared to those that were free-standing. The payment rates varied depending on local costs and ranged from $121 to $138 per treatment. Shortly thereafter, in 1986, the payments were reduced by $2 per treatment and an additional 50 cents was deducted to help defray the costs of the United States Renal Data System (USRDS). In constant 1974 dollars, therefore, actual payment for dialysis treatments had been cut by more than one-half by this time Figure 3. Small adjustments in the payments were made into the 1990s, but these have fallen far short of the costs of providing care. Some have speculated that the inadequacies of the current payment system adversely affect patient outcomes, but evidence supporting this contention is lacking11.Rettig R.A. Levinsky N.G. Kidney Failure and the Federal Government, National Academy Press, Washington, DC1991: 191-273Google Scholar,27.Rettig R.A. The politics of cost containment: end-stage renal disease.Bull NY Acad Med. 1980; 56: 115-138PubMed Google Scholar. MedPAC, the organization that advises Congress on Medicare payment policies, annually assesses the payment system for the entire program, including the ESRD component. Medicare payments and costs for dialysis services as well as injectable drugs are evaluated. Cost reports provided by the facilities are used to evaluate the costs of the dialysis treatment and erythropoietic-stimulating proteins (ESPs); Medicare claims data are used to evaluate the costs of other injectable drugs. The most recent such analysis shows a number of important trends25.Medicare Payment Advisory Commission: Report to the Congress: Medicare Payment Policy (March 2003), Washington, D.C.Google Scholar: the ratio of aggregate payments for dialysis and injectable drugs relative to costs has steadily declined to 1.04 overall. That is, for all facilities combined, there is a 4% margin provided by current Medicare payments; aggregate payments to small and nonprofit facilities do not cover the costs of providing dialysis services and injectable drugs, with a 1% and 2% loss, respectively. Payments for the dialysis treatment itself compared to costs also have declined significantly since 1996 and no longer cover the cost of treatment. Overall, facilities lose 3% on each dialysis treatment, with small and nonprofit facilities both losing 11% per treatment. MedPAC has taken the position that even though the costs of providing basic treatment exceed payments, facilities are able to compensate for this loss by profits on injectable drugs as well as cost-shifting from commercial insurance patients, in whom it is possible to assess higher charges. Because the payment for dialysis services is not updated annually for inflation, as are payments throughout the rest of the Medicare system, MedPAC has recommended a 1.6% increase in the payment for dialysis services in 2004. Such recommendations generally are not acted upon by Congress, the only entity currently empowered to adjust payments to dialysis facilities. A recent study commissioned by the Renal Leadership Council, a trade organization representing large-chain dialysis providers, has added an additional perspective to the analysis conducted by MedPAC28.White A.J. Mattke S. Hassol A. Updating the 2002 Composite Rate for Dialysis Treatments, Abt Associates Inc, Cambridge, MA2001Google Scholar. This study took issue with the MedPAC analysis in a number of areas, including the conclusions regarding profitability and productivity of the industry; the impact of industry consolidation; recent increases in labor, capital, drug acquisition, and overhead costs; arcane Medicare rules related to bad debt; Medical Director fees; and other legitimate, but not accepted (by Medicare) costs of providing dialysis services. Concern was expressed that quality of care would suffer if adequate payments were not provided, and specific recommendations for increasing payments were made. Previous studies, verified recently, suggest that patients in for-profit dialysis centers have a slightly higher mortality rate than do patients dialyzed in non-profit facilities; this finding suggests that the diversion of funds to profits, as is necessary in the for-profit environment, indeed might affect outcomes when profit margins are minimal29.Garg P.P. Powe N.R. Profit-making in the treatment of chronic kidney disease: Truth and consequences.Semin Dial. 2001; 14: 153-156Crossref PubMed Google Scholar,30.Szczech L. Chua B. FrankenfieLD D. et al.Dialysis facility profit status, dialysis care processes, and mortality in the CPM-USRDS dataset.J Am Soc Nephrol. 2003Google Scholar. In 1983 the Health Care Financing Administration (HCFA) (now the Centers for Medicare and Medicaid Services) (CMS) established the monthly capitated payment (MCP) for ESRD services that provided a set payment per month per patient31.Health Care Financing AdministrationFinal rule: Prospective Reimbursement for Dialysis Services.Fed Reg. 1983; 48: 21254-21291PubMed Google Scholar. The amount of the payment originally was derived by multiplying the payment amount for an office visit by a separate factor, theoretically capturing the scope of services provided by the nephrologist during the month. This system evolved since that time to represent a mix of evaluation and management (E&M) services, replacing the single office visit used in the initial model, and with other changes broadly associated with the implementation and refinement of the resource-based relative value system used for the overall Medicare physician fee schedule. What became a more significant issue for nephrology in recent years is the list of services that are represented by the MCP, as is true for any capitated payment. Similar to the MCP itself, this inventory of services had substantially evolved in recent years. The most significant milestone in this process was the publication in the Medicare Physician Fee Schedule (MFS) for Calendar Year 1996 of a list of services included in and excluded from the MCP that was developed by the Renal Physicians Association, reviewed and refined by the AMA's Relative Value Update Committee (RUC), and adopted by then-HCFA. Even though the publication of the list represented an important step forward with regard to the specificity of nephrologists' responsibilities in treating ESRD patients under their care, several issues not addressed either in this passage of the fee schedule or elsewhere had arisen over time and had become problematic. First, if nephrologists saw patients during an outpatient dialysis treatment and provide a service related to a non-renal condition (for example, diabetes or cardiovascular disease), separate billing was not permitted. The result was a significant barrier to the nephrologist taking on the role of principal care provider, which clinically is most appropriate. Second, ESRD patient services generally were not billable when these were provided in the Emergency Department, 23-hour holding areas, as well as in some skilled nursing facilities despite the fact that these sites of care required substantial additional work on the part of nephrologists. This problem produced an incentive to hospitalize patients. Third, no specific documentation requirements existed for services provided under the MCP. This led to confusion over what services had been provided and has been part of the impetus for a recent MCP change in the payment system for outpatient dialysis services. Fourth, the MCP did not provide sufficient consideration to the expenses involved with quality improvement and patient safety activities conducted by nephrologists, although nephrologists are expected to lead the continuous quality improvement (CQI) process in dialysis facilities and their own practices. Fifth, efforts at improving rehabilitation of patients are common, time consuming, and important, but not reimbursed. Finally, discrepancies remained in allowed payments among local carriers for a variety of physician services, with varying interpretations of what was included in the MCP and what was separately billable. In January 2004, a new payment system was introduced linking payment to the number of face-to-face visits in the dialysis facility. The new system is based on a hypothesis that more such visits will lead to better outcomes. This approach, however, has been widely criticized throughout the renal community. When considering payment policy, one must begin with the basics. The total cost of health care services is the product of the number of units of service provided, the unit cost, and the number of patients served, as well as the overall mix of services and service settings12.Farley D.O. Financing of end-stage renal disease care: Past, present and future.Adv Ren Replace Ther. 1994; 1: 24-31PubMed Google Scholar. For example, if the service provided is thrombolysis of a vascular access, the site of service (inpatient versus outpatient) would determine the unit cost and, this multiplier, times the number of thrombolysis procedures, determines the total cost to the system of providing the service. Any decrease in unit cost that accrued by moving vascular access care to the outpatient setting could be offset if the number of procedures performed increased substantially. Everything else being equal, however (number of units and number of patients), a decrease in unit cost would decrease total costs. Similarly, if patients are kept healthy through prospective coordination of care, hospitalizations will decrease, decreasing overall total costs8.Nissenson A.R. Collins A. Dickmeyer J. et al.Evaluation of disease-state management of dialysis patients.Am J Kidney Dis. 2001; 37: 938-944Abstract Full Text PDF PubMed Scopus (28) Google Scholar, 9.Nissenson A.R. Outcomes associated with a disease management program for end-state renal disease.Dis Man Health Outcomes. 2002; 10: 93-100Crossref Scopus (5) Google Scholar, 10.Nissenson A.R. Disease Management Improves Outcomes in Patients with CKD.Nephrology News Issues. 2003Google Scholar, 32.Mosley C. Coordination of care in disease management: Opportunities and financial issues.Semin Dial. 2000; 13: 346-350Crossref PubMed Scopus (16) Google Scholar. For the Medicare ESRD Program, the goals of payment policy should include: ensuring patient access to the highest quality care; equitable payment of providers of care for work performed, and control to the extent possible of the total costs of the Program. A number of studies have analyzed the costs of care for ESRD patients in a variety of settings, from individual dialysis programs to disease management organizations to the overall Medicare ESRD population3.U.S. Renal Data SystemUSRDS 2003 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2003Google Scholar, 8.Nissenson A.R. Collins A. Dickmeyer J. et al.Evaluation of disease-state management of dialysis patients.Am J Kidney Dis. 2001; 37: 938-944Abstract Full Text PDF PubMed Scopus (28) Google Scholar, 9.Nissenson A.R. Outcomes associated with a disease management program for end-state renal disease.Dis Man Health Outcomes. 2002; 10: 93-100Crossref Scopus (5) Google Scholar, 10.Nissenson A.R. Disease Management Improves Outcomes in Patients with CKD.Nephrology News Issues. 2003Google Scholar, 12.Farley D.O. Financing of end-stage renal disease care: Past, present and future.Adv Ren Replace Ther. 1994; 1: 24-31PubMed Google Scholar, 13.Nissenson A.R. Daily hemodialysis: Challenges and opportunities in the delivery and financing of end-stage renal disease patient care.Adv Ren Replace Ther. 2001; 8: 286-292Abstract Full Text PDF PubMed Scopus (11) Google Scholar. As one might expect, only 25% of ESRD patients account for nearly 50% of all costs, and inpatient care accounts for ne
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