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Renal by Minnie: AH Version > Renal HS > Flashcards

Renal HS Flashcards

1
Q

Besides insurance coverage, what major shifts did the affordable care act emphasize?

A
  • Value-based purchasing
  • Alternative payment models
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2
Q

What are the unintended consequences of “dialysis for all”?

A
  • Olderer patients and sicker patients are routinely on dialysis
    • Even if it will not really help their outcomes – no “shared decision making”
    • Because it is widely available and clearly prolongs life, hard for clinicans to withold and patients to refuse
  • Hemodialysis incentivized (over peritoneal)
    • Most expensive treatment
    • Covered by medicare
    • -> Many for-profit dialysis centers (a big business)
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3
Q

What kind of insurance covers dialysis?

A

Anyone with ESRD qualifies for medicare, and medicare covers dialysis

ESRD is the only disease that can qualify a person for medicare coverage

However, for patients with private insurance, their insurance is responsible for the first 30 months of dialysis costs until they are medicare eligible

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4
Q

What are balancing measures?

A

Efforts to ensure that changes do not have unintended consequences

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5
Q

How is dialysis different in other countries vs. the United States?

A

Other countries (like South Africa) have more stringent requirements on who qualifies for dialysis

(Age, BMI, HIV negative, HepB negative, no other “negative factors”)

=> There are fewer people on dialysis in South Africa than in America (although I don’t see this being very equitable)

Hong Kong has a “peritoneal dialysis first” policy - this helps to reduce costs

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6
Q

What are the fluid intake guidelines for patients with CKD?

A

There are no specific guidelines, but it is generally recommended that patients don’t drink excessive fluids

Note: Many patients with CKD also have heart failure - limit fluids to 1.5 to 2 L/day in patients with heart failure

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7
Q

Give some examples of health care outcomes

A
  • Survival
    • Ex: Mortality benefit after recieving the flu vaccine
  • Improved functional capabilities
  • Reduction of pain and suffering
  • Ability to engage in normal life
    • Ex: number of days until a patient can walk after hip surgery
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8
Q

Which reimbursement system would incentivize physicians to accept patints that are healthier to minimize time spent and services rendered and to maximize the amount they receive per patient?

A

Capitation

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9
Q

What reimbursment system payes a certain amount based on a patient’s diagnosis?

A

Payment by episode of illness

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10
Q

What is the leading cause of mortality in patients with CKD?

A

Cardiovascular disease

  • Increased phosphorous can contribute
  • -> Calcification, FGF-23 release
    • -> Cardiovascular remodeling
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11
Q

What are “professional” healthcare services?

What kind of insurance covers these services?

A
  • Services provided by a healthcare professional –
    • Office visits, consults, surgeon’s fee, etc.
  • Covered by Medicare Part B or private insurance
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12
Q

Which organization convenes to develop a standard patient outcome measurement set?

Why is this important?

A

International Consortioum of Health Outcome Measures (ICHOM)

This makes implementing these measure sets easier, because individual phsyicians and hospitals don’t have to sort through all of the potential tools that they might use - ICHOM has already met and decided upon the best measure sets to used for each patient population/condition

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13
Q

African Americans represent 13.2% of the US population, yet constitute more than ____% of all patients in the US receiving dialysis for ESKD

A

African Americans represent 13.2% of the US population, yet constitute more than 35% of all patients in the US receiving dialysis for ESKD

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14
Q

What are the challenges of using PROMs to improve health outcomes?

A

Data is not easy to maintain and integrate

  • Requires longer contact time post-treatment
  • Can be burdensome and time-consuming
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15
Q

What drug improved kidney transplant outcomes in the 1980’s?

A

Cyclosporin

An immunosuppressant (calcineurin inhibitor)

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16
Q

Healthcare represents ____% of the United States GDP

A

Healthcare represents 28% of the United States GDP

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17
Q

For patients with established end stage renal disease, the most effective form of renal replacement therapy is:

  1. Daily, home hemodialysis
  2. Peritoneal dialysis
  3. Deceased donor kidney transplant
  4. Living, incompatible kidney transplant
  5. Living, compatible kidney transplant
A

e. Living, compatible kidney transplant

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18
Q

What is kidney paired donation?

A

“Kidney exchange”

An incompatible donor donates to the pool, in return for a different living donor’s kidney (if their desired recipient is also incompatible with their donor)

All transplants must occur simultaneoulsy (but they do not have to take place at the same center)

This allows for more well-matched living donor transplants

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19
Q

Why does low birth weight correlate with increased risk of developing CKD?

A

Low birth weight

= Smaller kidneys

= Reduced nephron number

= Mismatch between kidney capacity adn adult excretory load

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20
Q

How are kidney allografts monitored?

A

Biopsy

  • More invasive, but can more accurately detect subclinical injury/rejection
  • Important to monitor in order to ensure proper dose of immunosuppressants
    • Too much = nephrotoxicity, infection risk
    • Too little = rejection
  • Blood-based test for subacute clinical rejection is being developed
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21
Q

What are “bundled payments?”

How do they compare to “fee for service?”

A

Bundled payments = an alternative payment model built around defined episodes of care

A single case rate or target price makes the providers financially accounable for all services in the specified time frame

Providers will be reimbursed a fixed amount - this incentivizes the proiver to ensure high-quality, cost-effective care

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22
Q

What disparities may exist in the development of precision medicine may exist in CKD?

A

The human reference genome that is used to guide precision medicine does not contain all ancestral genomes and variations in equal representation

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23
Q

What is the inheritance pattern of the APOL1 G1 and G2 alleles?

A

Autosomal recessive w/incomplete penetranc

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24
Q

What is the prevalence of CKD?

A

>30 million Americans have CKD

(14% of the population)

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25
Q

Which of the following is not required by the FDA to be placed on nutrition labels?

a. Serving size
b. Sodium content in mg
c. Saturated fat
d. Phosphorus content

A

d. Phosphorus content

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26
Q

What is a racial difference in health?

Give examples

A

Clinical, biological, genetic, or epigenetic factors associated with disease risk or outcome

Not caused by social factors that vary among population groups

  • Preference to forego surgery for cultural reasons
  • Genetic predisposition for progression of CKD
    • Ex: APOL1 mutation in African Americans makes progression to ESRD more likely in patients with CKD
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27
Q

For-profit dialysis patients have a _____% higher mortality rate than patients receiving dialysis from centers that were not for-profit

A

For-profit dialysis patients have a 13% higher mortality rate than patients receiving dialysis from centers that were not for-profit

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28
Q

How do you convert from sodium to the approximate salt equivalent?

A

Salt = sodium * 2.5

Half the salt molecule is sodium, it’s not half the weight
(40% is sodium, 60% is chloride)

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29
Q

ESRD expenditures account for _____% of Medicare budget

ESRD patients account for _____% of Medicare beneficiaries

A

ESRD expenditures account for 7% of Medicare budget

ESRD patients account for <1% of Medicare beneficiaries

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30
Q

Compare the cost of hemodialysis, peritoneal dialysis, and transplant over the course of a year

A

Hemodialysis = most expensive

Peritoneal dialysis

Transplant = least expensive

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31
Q

What is the recommendation for protein intake in patients with CKD?

Why?

A

Limit protein intake

Excess protein can lead to accumulation of uremic toxins

This can accelerate decline in renal function and progression of CKD

However, this can lead to lean body mass and malnutrition, so don’t go overboard

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32
Q

What are the relevant racial disparities in CKD?

A
  • Healthare access
    • Decreased access to preventative care
    • -> Decreased referrals to nephrology
  • Access to kidney transplant
    • Less likely to…
      • Be identified as a transplant candidate
      • Receive transplant evaluation referral
      • Be placed on the waiting list for deceased donor kidneys
  • Living and working ocnditions
    • Worse dialysis facilities
    • More toxic waste sites
    • Fewer walkable areas
    • More food deserts
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33
Q

What are the key differences between episode-based payment models and population-based payment models?

A
  • Episode-based
    • Centered around a “triggering event”
    • Duration depends on the triggering event, but is generally meant to just manage that event
  • Population-based = ACO
    • Aimed at managing the care of an entire population
    • Long-term
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34
Q

Describe global payment as a reimbursement system

A

A fixed payment is made for all services for a specified period of time

Ex: The Veteran’s Health Administration, Department of Defense, and Kaiser Permanente hospitals are paid via global budgets

  • Every service performed on every patient during a year is aggregated into a single payment
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35
Q

What defines an “episode of care?”

A

An episode of care is defined by a

  • Treatement and/or condition…
  • For a specified period of time both before and after the triggering event
  • By a set of care providers and services rendered within the episode

Example: hip replacement

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36
Q

What is the International Consortioum of Health Outcome Measures (ICHOM)?

A

A non-profit organization that aims to accelerate teh use of patient outcome measurement in healthcare

They get patients and physicians together to develop standard patient outcome measurement sets

This allows for the identification of measure sets that can be used for improvement, without getting lost in the weeds

Measure sets have been developed to measure otcomes from strokes, acute renal failure, prolonged ventilation, etc

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37
Q

What are “facility” healthcare services?

What kind of insurance covers these services?

A
  • Anything where a “facility” needs to be used
    • Hospital stays, skilled nursing stays, outpatient surgery
  • Covered by Medicare Part A or private insurance
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38
Q

Why are PROMs (Patient Reported Outcome Measures” important?

A

They capture whether services provided actually improved a patient’s health and sense of well-being from the perspective of the patient

They ask the patinet “how are you?”

rather than “how were we?”

39
Q

What are the relevant racial differences in CKD

A
  • Cardiometabolic risk factors
    • But management of these risk factors is influenced by disparities, so this isn’t purely a “difference”
  • APOL1 Mutation
40
Q

What is the differnece between the MIPS and A-APM quality payment plans?

(Implemented by the MACRA legislation)

A

Both create a formula for how the medicare fee schedule adjusts yearly

  • MIPS
    • Tracks performance across 4 domains
    • Quality, cost, improvement activities, interoperability
    • More providers are on this track
  • A-APM
    • 5% incentive for achieving total threshold levels of payments
41
Q

Rank the following on the spectrum from “fee for service” to “global payments”

  • Condition specific capitation
  • Multi-provider bundled episode-of-care payment
  • Per Diem
  • Episode-of-care payment
  • Full capitation
A

Fee for service = physicians $$ rewarded for providing more care

  • Per Diem payments
  • Episode-of-care payment
  • Multi-provider bundled episode-of-care payment
  • Condition specific capitation
  • Full capitation

Global payments = provider or hospital is given a lump sum annually for all services. This is the most extreme form of bundled payments

42
Q

What components of value-based payment models will increase our ability to manage population?

A
  • Clinically aligned provider network
  • Information management platform
  • Care model innovation and enhancements
43
Q

Which country in the world spends the most money on healthcare, per capita?

A

United States

44
Q

The average calcium intake in US adults is…

A

1-1.2 grams

45
Q

What is an accountable care organization (ACO)?

A

A network of doctors, hospitals, and other providers that share responsibility for managing the care of populations

Payment designs usually evaluate the cost of care over a year vs a benchmark, and performance on key quality measures

Examples: “shared savings,” “capitated payment”

46
Q

What is time-driven activity-based costing (TDABC)?

A

A system of calculating costs that takes into account the time each person in the hospital spends with the patient and the time spent using specific equipment with each patinet.

The total cost is based off of this time and the salaries and overheads associated with each person and piece of equipment.

More transparent than current costing methods

47
Q

What is longevity matching?

A
  • Give the longest-lasting kidneys to the longest-living recipients
  • Keeps these people off of the transplant list in the futur
  • Justified by the idea of “fair innings” – everyone should have the same chance of turning 50
    • (In baseball, fair innings = each batter bats 9 times)
48
Q

What is CMMI?

What do they do?

A

Center for Medicare and Medicaid Innovation (CMMI)

They come out with new models for how to pay for healthcare

  • They want providers to participate in alternative payment model pilots that incentivize coordination of care
49
Q

Value-based health care = _______ /_________

A

Value-based health care =
Outcomes that matter to patients / Total costs of care

50
Q

How does the region you live in currently impact kidney transplantation?

How will this change by the end of 2020?

A

Regions are currently based on arbitrary “donor service ares” for each transplant center - You can be put on the list for that area if you have the means to get there

State lines and “accidents of geography” can make people living in certain areas much more likely to recieve a life-saving organ transplant

By the end of 2020, kidney tranplantation will move to a “concentric circle” system, where up to 2 points can be awarded for proximity to the transplantation center

51
Q

What percentage of total health care dollars are wasted every year?

A

30%

(This means that almost 1/3 of the dollars spent on healthcare are not making people healthier)

52
Q

Outcome measures are needed to know ______

Process measures are needed to know ______

A

Outcome measures are needed to know what works

Process measures are needed to know what inputs and activities achieved the result

53
Q

Why have the G1 and G2 alleles of APOL1 been maintained in populations of African descent?

A
  • Heterozygosity (G1/G0 or G2/G0) confers protection against dying from African trypanosomiasis
  • Homozygosity (G1/G1, G2/G2, G1/G2) confers protection, but also increases risk of developing CKD
    • But only a minority of people with the “high risk alleles” develop CKD = incomplete penetrance
54
Q

How does tracking health outcomes support the professionalism of clinicians?

A

Tracking outcomes gives clinicians feedback about what is working and what isn’t.

Identifying, measuring, and improving outcomes can help to improve clinical practice

55
Q

What is a racial disparity in health? Give examples

A

Health differences that adversely affect disadvantaged populations based on one or more health outcomes

Usually result from the operation of healthcare systems, legal and regulatory climates, and discriminatory biases

  • Healthcare access
  • Living and working conditions
  • Referrals for life-saving treatment (ex: kidney transplant)
56
Q

What is a process measure?

A

The things that are done in giving and receiving care

In order to be vaild, process measures keep track of things that have been previously emonstrated to produce a better outcome, and whether or not those things were done during a particular encounter

Ex: Giving a flu vaccine during a hospitalization

57
Q

Who does MACRA/QPP apply to?

A

Most physicians and advanced practice providers (ex: nurse practitioners) who care for medicare patients

58
Q

What is the biggest contributor to heatlh care waste?

A

Unnecessary services

59
Q

What are the major sources of dietary phosphorous?

A
  • Organic
    • Animal products
    • Dairy
    • Vegetables
  • Inorganic
    • Additives - Very readily absorbed
      • Soda, diet soda
      • Flavor enhancers
      • Preservatives
      • Stabilizers
60
Q

The dollar ammount that it costs for a provider to deliver a health care service is the…

  1. Cost
  2. Charge
  3. Price
  4. Reimbursement
A

a. Cost

61
Q

The KDIGO guidelines recommend ______ grams of sodium intake/day

A

The KDIGO guidelines recommend <2 grams of sodium intake/day

62
Q

The dollar amount that a health care provider asks for a service is the…

  1. Cost
  2. Charge
  3. Price
  4. Reimbursement
A

b. Charge

Often much higher than the actual cost and reimbursement

63
Q

Can tolerance be induced to avoid long-term immunosuppression?

A

Yes!

Chimeris can induce tolerance

  • Combined kidney/stem-cell transplant can induce chimerism
    • Stem cells transplanted concurrently with the kidney, these cells recognize the kidney as “self”
    • (The actual procedure is more complicated than this and super cool, but I’m skipping over it)
  • Risk: Foreign immune cells may recognize the host as foreign
    • -> graft vs. host disease
64
Q

What are the drivers of the new national kidney allocation policy (2014)?

A
  • Wating time = main driver

Also give points for…

  • HLA match
  • Multi-organ transplants (ex: getting liver and kidney)
  • Pediatric patients
  • Longevity matching
    • Gives the longest lasting kidneys to the longest living recipients
65
Q

What are outcome measures?

A

The effects of care on the health status of patients and populations

These should focus on what matters to the patient

Ex:

  • Fewer people dying after receiving a flu vaccine in the hospital
  • Comfort after joint replacement
66
Q

What is the “quadruple aim” for reforming health delivery and payment?

A
  • Improve quality of outcomes
  • Lower the cost of care
  • Improve the patient experience
  • Improve the physician experience
67
Q

What factors are accounted for in payment designs for ACOs?

A

Total cost of care over a year (vs. a benchmark)

Performance on key quality measures

68
Q

List the kidney distribution priorities

A

In order from highest -> lowest priority

  • Highest CPRA candidates (hardest to match)
  • Kidney + extra-renal organ (sickest)
  • Zero antigen mismatch (Best outcome)
  • Prior living donors (most deserving)
  • Pediatrics
  • Everybody else
69
Q

The new initiative for “Advancing American Kidney Health” incentivizes which two interventions?

A

Home dialysis

Preemptive kidney transplant

70
Q

What is a “health care outcome?”

A

The result of care on the health of patients, families, and populations

Examples of outcomes include:

  • Survival
  • Improved functional capabilities
  • Reduction of pain and suffering
  • Ability to engage in normal life
71
Q

The dollar amount that a patient pays out of pocket for a service is the…

  1. Cost
  2. Charge
  3. Price
  4. Reimbursement
A

c. Price

72
Q

We are trying to move toward a more value-based healthcare system, but we currently have a _______-based healthcare system

A

We are trying to move toward a more value-based healthcare system, but we currently have a volume -based healthcare system

73
Q

What is a patient-reported outcome measure (PROM )?

A

A subset of patient outcomes

Capture the patient’s sense of their own health and well-being - these are the outcomes we care about!

ICHOM = a resource for measuring patient outcomes (ex: which ones to measure)

74
Q

How does measurement of GFR contribute to racial disparities in CKD?

A

Correction for race in African Americans may underdiagnose CKD at early stages

75
Q

What principles guide the National Organ Transplant Act?

A

Justice and Medical utility

  • Justice priortitizes patients with the greatest need
    • Pediatric patients
    • Patients who have been waiting the longest
    • Patients who are highly sensitized (hard to HLA match
  • Medical utility provides the greatest good for the greatest number
    • Promotes the longest survival of organs
    • Minimizes the wastage of organs
76
Q

“Fee-for-service” systems incentivize __________

A

“Fee-for-service” systems incentivize volume

The more services a physician can provide, the more they will be paid - does not incentivize quality

77
Q

What are the 4 programmatic elements of the MIPS alternative-payment track?

A
  • Quality (45%)
  • Cost (15%)
  • Improvement activities (15%)
  • Promoting interoperability (25%)
78
Q

Which alleles of APOL1 are more common in African American populations?

Why?

A

G1 and G2 (G0 is the reference allele)

  • Heterozygosity (G1/G0 or G2/G0) confers protection against dying from African trypanosomiasis
  • Homozygosity (G1/G1, G2/G2, G1/G2) confers protection, but also increases risk of developing CKD
    • But only a minority of people with the “high risk alleles” develop CKD = incomplete penetrance
79
Q

What foods have high potassium content?

A
  • Bananas
  • Mango
  • Oranges/orange juice
  • Raisins
  • Potatoes
  • Tomatoes
  • Black beans
  • Salmon
  • Chocolate
  • Milk
  • Peanut butter

Should be avoided in patients with Stage 3b CKD (GFR <45 mL/min) or worse

80
Q

Describe the Per Diem Payment reimbursement system

A

A hospital is paid a bundles fee for all services delivered to a patient in a single day

81
Q

The average potassium intake for adults in the US is ______ grams

A

The Average potassium intake for adults in the US is 2.5 grams

82
Q

List the 6 biggest contributors to health care waste, in order from most to least wasteful

A
  1. Unnecessary services
  2. Excessive administrative costs
  3. Inefficeint care due to systems errors and failures of coordination
  4. Prices that are excessively high
  5. Fraud
  6. Missed prevention opportunities
83
Q

What is the National Organ Transplant Act (1984)?

A

The act stating that the organ allocation system must be balanced and defensible

Based on Justice and Medical Utility

  • Justice recognizes patients with the greatest need
  • Medical utility provides the greatest good for the greatest number
84
Q

The average phosphorus intake for adults in the US is _____ grams

A

The average phosphorus intake for adults in the US is 1.2-1.7 grams

85
Q

The dollar amount a third-party payer (ex: insurance) negotiates as payment to the provider is the…

  1. Cost
  2. Charge
  3. Price
  4. Reimbursement
A

d. Reimbursement

86
Q

What factors are driving the changing healthcare landscape?

A
  • Economic forces
    • Rising healthcare costs
  • Market dynamics
    • Commercial payer consolidation
    • Pressure for providers to assume risk
  • Changing consumers
    • More informed, empowered, technology savy
    • Desire cost transparency
  • Policies
    • Affordable care act
    • Value-based payment programs
    • CMMI (Center for Medicare and Medicaid Innovation)
87
Q

What are the two MACRA/QPP tracks for physician payment?

A

Both are quality payment plans (tracks) estabilished by the MACRA legislation

  • MIPS
    • Merit-based incentive payment system
    • Most providers participate in this
    • Scored on quality (45%), cost, improvement activities, and promoting interoperability (computer systems talking)
  • A-APM
    • Advanced Alternative Payment Model
    • Only a few qualifying models
88
Q

What is MACRA?

A

Medicare Access and CHIP Reauthorization Act (2015)

The system for determining how physician salaries increase year after year

  • Bipartisan legislation passed in 2015
  • Incentivizes value-based care
    • Merit-based system
    • Pay increased with quality and performance
  • Replaced the Sustainable Growth Rate (SGR) method for fee-schedule adjustments
    • The SGR method was flawed - physician pay cuts!
89
Q

Describe capitation as a reimbursement mechanism

A

A healthcare provider is paide for providing services to a number of people

  • Amount paid is determined by the number of total patients
  • Provider receives a service fee “per head” for providing a defined package of service for a specified time
90
Q

What is health care waste?

A

Anything we do in healthcare that doesn’t make people healthier

Ex: Tests, medications, and procedures that are not making people healthier

91
Q

What is a structure measure?

A

The materal, human, and organizational resources available in the setting in which care is delivered

Ex: the number of hospital beds, available staff, etc.

92
Q

The most common cause of kidney transplant (graft) failure is…

  1. Rejection
  2. Infection
  3. Death with functioning graft
  4. Medication toxicity
A

C. Death with functioning graft

93
Q

Whether a pateint with a heart attack is prescribed an ace inihbitor medication prior to discharge is a…

  1. Process measure
  2. Outcome measure
  3. Structural measure
A

a. Process measure

Renal by Minnie: AH Version (27 decks)

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