The Centers for Medicare & Medicaid services (CMS) proposes to change the method of reimbursement for outpatient hemodialysis such that a fixed payment bundle will cover both outpatient dialysis therapy and injectable medications. This document suggest that African American patient have a lower haemoglobin count than whites and therefore would require a more costly treatment.
¶ … medical care to African-Americans. The purpose of the article is clearly stated as it reveals the proposition of the Centers for Medicare & Medicaid services (CMS) to adjust the procedure compensated by outpatient hemodialysis. The current procedure sees the billing of the outpatient dialysis done at a fixed rate. The billing of the intravenous (IV) medication is separate on a dosage basis. Currently, outpatient billing has increased revenues in the dialysis facility because of higher use of IV dosage resulting to increased medication in the outpatient IV. The study population is towards the African-Americans as they have started dialysis with less concentration in hemoglobin than whites. It is also unlikely that they had any Erythropoiesis Stimulating Agent (ESA) therapy prior to beginning dialysis. However, they have the same outcomes for whites and African-Americans for certain concentrations in hemoglobin. In order for these results to be similar, African-Americans will need higher doses of ESA putting in mind poorer dialysis, intrinsic resistance, and higher weight. Other elements that affect results are age, body surface area, Body Mass Index (BMI). These are some of the methods that the author has put in mind in the study to get the right desired effects of dialysis. We see the inclusion of different patients ranging from age to the type of medication and Medicare they have. The proposal is to try and change the difference in cost in patients through utilizing fundamental case-mix data to modify the capacitated payment for dialysis on a monthly basis.
Methods
There are different methods used to get desired results in the study. The use of Erythropoiesis Stimulating Agent (ESA) therapy has been stated as an essential procedure before starting the dialysis process. The methods used are to ensure that the African-Americans pay the same amount for treatment as the whites. The methods involve using adjusters such as age, body surfaced area, BMI and locality to the base payment. There are no race adjusters, something that is currently on debate. Other methods used included predictable variables such as EPO doses, baseline characteristics and use of statistics in system codes.
The methods involved the use of naive patients on ESA who started dialysis between January and October of 2006. The age requirement was above 67 years of age during their initiation of dialysis. It was a requirement that the participants have had Medicare as their main supply of insurance two years before initiating dialysis. To make sure that no participants had involvement in ESA use, coding systems were used to eliminate them from the study. Patients that had already undertaken the ESA medication had Healthcare Common Procedure Coding System codes, revenue codes and value codes in their Medicare claims. The cohort entry also included that the participants must have undergone EPA therapy in the first two months after starting hemodialysis.
The determination of use of EPO doses was through the use of outpatient EPO from their insurance claims. This information was obtained from the facilities giving dialysis and it was for the first two months only. The study excluded darbepoetin doses as it had only been administered to a few patients. Inpatient EPO doses were not easily determinable as they are not billed differently to Medicare. The use of outpatient EPO only may be underestimating the total use of the medication. The cohort dealt with the biasness by determining the amount of time a patient stayed in hospital. The calculations on the average dose of EPO for every patient per day was by adding the total dose for a whole month then separating it by the number of days of outpatient then multiplying by 30 to get the total of a calendar month. According to the medical reports the study used the right amount of doses. The study was not randomized as it was aimed towards the African-American population. The statistics were right as they compared the characteristics of the baseline by using two tests for categorical variables and n tests for continuous ones; this shows that the study was not randomized.
Results
The study group is of 40,942 patients of 67 years of age who were on hemodialysis. The race of an individual as well as their age, weight and BMI and access type affected the results of the dialysis. The results were clearly stated. Due to distortion in the distribution of EPO doses, the study removed 0.25% of patients on equally parts of the mean. The present participants were the same to those excluded in exception of involvement of older participants, and logistic regression analysis. The p values were available in the statistics of ratios.
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