Dialysis is a limited resource within the VA, requiring many veterans with ESRD to receive dialysis treatment from non-VA providers on a fee basis. Historically, inconsistencies in VA payment policies to these fee dialysis providers resulted in highly variable payments that often exceeded those paid by Medicare. Effective January 1, 2009, VA mandated system-wide use of the Medicare fee schedule for non-VA dialysis treatments. Standardizing VA payment of dialysis services may control costs of VA spending on non-VA dialysis care, but this policy raises several important and potential unintended consequences of this new payment policy on (1) patient access to community-based dialysis; (2) demand for treatment at already constrained VA dialysis units; and (3) quality and outcomes of care for veterans with ESRD. Currently, the evidence base on chronic dialysis care in the VA system provides limited guidance on the effects this new payment policy will have on veterans' care. In order to examine the effects of this new reimbursement policy for ESRD, it is important to understand the context of veterans' ESRD care before the new payment policy was implemented in January 2009. The objectives of this pilot study are to examine demand, payment, and care coordination of VA dialysis care prior to the January 2009 reimbursement policy to non-VA dialysis providers. Specifically, this study will 1) assess the demand of outpatient dialysis treatment among ESRD veterans and 2) examine the variation in payments to fee dialysis providers and whether this payment variation correlates with the use of non-VA dialysis services before January 2009. This study will employ longitudinal cohort design to explore VA ESRD services in 2 VISNs between 2007 and 2008. VA administrative data will be used to assess the extent of VA's use of VA and non-VA dialysis services. Variations in dialysis utilization and payments to non-VA providers will also be examined before the new payment policy was implemented. Results from this analysis will inform the development of hypotheses, identification of key variables and outcomes, and determine the statistical power for a larger, national evaluation of the consequences of the reimbursement policy on veterans' access and quality of VA and non- VA ESRD care.
VA has increasingly relied on non-VA providers for chronic outpatient dialysis services for patients with end-stage renal disease (ESRD). Recent changes in VA reimbursement policy to non-VA providers may change local structures and processes of dialysis care coordination in ways that adversely affect quality and outcomes of ESRD veterans. This pilot study will evaluate the context and patterns of VA's delivery of dialysis treatment by examining VA's demand for dialysis and how VA meets this demand with VA and non-VA providers before the new policy was implemented. This pilot research will provide preliminary data needed for subsequent evaluation of VA's ESRD payment policies on a national scale. Findings from this study will also help VA assess its capacity to meet patients'need for life-sustaining and costly ESRD care.
