Physician reimbursement for outpatient dialysis care: Past, present, and future

Is Dialysis Nephrology's Original Sin?

The introduction of hemodialysis in the 1960s and the subsequent enactment of Medicare coverage in 1972 came to shape the evolution of nephrology as a specialty. The subsequent focus on dialysis care as a principal form of reimbursement led to a host of benefits and challenges for nephrologists. While the specialty initially enjoyed great popularity and exponential growth, a widening schism between researchers and clinicians developed. This limited the growth of robust clinical research in nephrology while dialysis care encumbered clinicians with exhausting travel, routinized rounding schedules, and burdensome navigation of electronic medical record systems. Poor morale and burnout among practitioners, coupled with the ethical issues associated with corporatized medicine have resulted in severe challenges for the specialty including difficulties with recruitment. The history of nephrology elucidates the convergence of medical science, public policy, and corporatization while providing a lens on the wider issues of contemporary American health care. Ongoing efforts to refocus nephrology on preventive care in chronic kidney disease, new diagnostic and treatment modalities, and shifting of dialysis care to nonphysician providers should be accelerated.

Policy and Payment Decisions on Peritoneal Dialysis in the United States: A Review

End-stage kidney disease (ESKD) accounts for a sizable proportion of Medicare spending. Peritoneal dialysis remains an underutilized treatment modality for ESKD despite its quality of life and cost-saving benefits. Medicare policy on reimbursements and patient eligibility for dialysis coverage has been amended numerous times since its inception in 1972. Over the last two decades, Medicare policy on ESKD reimbursements has evolved from a primarily fee-for-service model to a prospective payment system, and within the past few years, it has begun including more experimental payment structures. While prior work has explored the evolution of Medicare's ESKD policy as a whole, we specifically outline the impact of Medicare policy changes on peritoneal dialysis reimbursement rates, uptake by physicians and dialysis facilities, and accessibility to patients. This narrative review offers historical insights, an overview of modern ESKD policy, actionable strategies, and policy opportunities to increase the accessibility of this treatment modality.

Postgraduate Education and Training for the Nephrology Physician Assistants and Nurse Practitioners

There is no consistent educational model to introduce the physician assistant and/or nurse practitioner to nephrology. The job descriptions of the nephrology physician assistant/nurse practitioner may be similar, but the training, state and federal licensing, background, and recertification are different for the 2 professions adding a level of complexity to the training of the physician assistant/nurse practitioner new to nephrology. On-the-job training is the most common modality, but formats, content, mentors, and practices vary from organization to organization and even within organizations. The advantage of on-the-job training is its flexibility while the disadvantage is its nonspecific outcomes. As nephrology practices vary widely and range from single provider private practices to multiprovider academic practices, it is difficult if not impossible to develop a generic orientation model. This article outlines the history and present state of postgraduate educational offerings for the physician assistant/nurse practitioner and provides insight into components of an ideal training program.

The changing landscape of PAs and NPs in nephrology

BACKGROUND

Physician assistants (PAs) and NPs have expanded roles in nephrology as both the patient load and acuity of care needed for this population have increased.

PURPOSE

To evaluate the workforce patterns of PAs and NPs working in nephrology over the past decade.

METHODS

Using the biannual survey from the National Kidney Foundation Council of Advanced Practitioners, data were collected and analyzed over the past decade.

RESULTS

Surveys of nephrology practitioners show the evolution of the dialysis-focused practitioner to one encompassing all aspects of nephrology: hospital, ICU, research, office, and all types of dialysis. Salaries and benefits have increased to compensate for the expansion of responsibilities.

CONCLUSIONS

PAs and NPs in nephrology have the opportunity to use their skills and training in caring for this high-risk population.

The changing landscape of nephrology physician assistants and nurse practitioners

BACKGROUND

Physician assistants (PAs) and nurse practitioners (NPs) have expanded roles in nephrology as both the patient load and acuity of care needed for this population have increased.

PURPOSE

To evaluate workforce patterns of PAs and NPs working in nephrology over the past decade.

METHODS

Using the biannual survey from the National Kidney Foundation Council of Advanced Practitioners, data were collected and analyzed over the past decade.

RESULTS

Surveys of nephrology practitioners show the evolution of the dialysis-centralized practitioner to one encompassing all aspects of nephrology: hospital, intensive care unit, research, office, and all types of dialysis. Salaries and benefits have increased to compensate for the expansion of responsibilities.

IMPLICATIONS FOR PRACTICE

Physician assistants and NPs in nephrology have the opportunity to use their skills and training in caring for this high-risk population.