Renal HS Flashcards
Besides insurance coverage, what major shifts did the affordable care act emphasize?
- Value-based purchasing
- Alternative payment models
What are the unintended consequences of “dialysis for all”?
- 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)
What kind of insurance covers dialysis?
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
What are balancing measures?
Efforts to ensure that changes do not have unintended consequences
How is dialysis different in other countries vs. the United States?
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
What are the fluid intake guidelines for patients with CKD?
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
Give some examples of health care outcomes
- 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
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?
Capitation
What reimbursment system payes a certain amount based on a patient’s diagnosis?
Payment by episode of illness
What is the leading cause of mortality in patients with CKD?
Cardiovascular disease
- Increased phosphorous can contribute
- -> Calcification, FGF-23 release
- -> Cardiovascular remodeling
What are “professional” healthcare services?
What kind of insurance covers these services?
- Services provided by a healthcare professional –
- Office visits, consults, surgeon’s fee, etc.
- Covered by Medicare Part B or private insurance
Which organization convenes to develop a standard patient outcome measurement set?
Why is this important?
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
African Americans represent 13.2% of the US population, yet constitute more than ____% of all patients in the US receiving dialysis for ESKD
African Americans represent 13.2% of the US population, yet constitute more than 35% of all patients in the US receiving dialysis for ESKD
What are the challenges of using PROMs to improve health outcomes?
Data is not easy to maintain and integrate
- Requires longer contact time post-treatment
- Can be burdensome and time-consuming
What drug improved kidney transplant outcomes in the 1980’s?
Cyclosporin
An immunosuppressant (calcineurin inhibitor)
Healthcare represents ____% of the United States GDP
Healthcare represents 28% of the United States GDP
For patients with established end stage renal disease, the most effective form of renal replacement therapy is:
- Daily, home hemodialysis
- Peritoneal dialysis
- Deceased donor kidney transplant
- Living, incompatible kidney transplant
- Living, compatible kidney transplant
e. Living, compatible kidney transplant
What is kidney paired donation?
“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
Why does low birth weight correlate with increased risk of developing CKD?
Low birth weight
= Smaller kidneys
= Reduced nephron number
= Mismatch between kidney capacity adn adult excretory load
How are kidney allografts monitored?
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
What are “bundled payments?”
How do they compare to “fee for service?”
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
What disparities may exist in the development of precision medicine may exist in CKD?
The human reference genome that is used to guide precision medicine does not contain all ancestral genomes and variations in equal representation
What is the inheritance pattern of the APOL1 G1 and G2 alleles?
Autosomal recessive w/incomplete penetranc
What is the prevalence of CKD?
>30 million Americans have CKD
(14% of the population)
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
d. Phosphorus content
What is a racial difference in health?
Give examples
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
For-profit dialysis patients have a _____% higher mortality rate than patients receiving dialysis from centers that were not for-profit
For-profit dialysis patients have a 13% higher mortality rate than patients receiving dialysis from centers that were not for-profit
How do you convert from sodium to the approximate salt equivalent?
Salt = sodium * 2.5
Half the salt molecule is sodium, it’s not half the weight
(40% is sodium, 60% is chloride)
ESRD expenditures account for _____% of Medicare budget
ESRD patients account for _____% of Medicare beneficiaries
ESRD expenditures account for 7% of Medicare budget
ESRD patients account for <1% of Medicare beneficiaries
Compare the cost of hemodialysis, peritoneal dialysis, and transplant over the course of a year
Hemodialysis = most expensive
Peritoneal dialysis
Transplant = least expensive
What is the recommendation for protein intake in patients with CKD?
Why?
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
What are the relevant racial disparities in CKD?
- 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
- Less likely to…
- Living and working ocnditions
- Worse dialysis facilities
- More toxic waste sites
- Fewer walkable areas
- More food deserts
What are the key differences between episode-based payment models and population-based payment models?
- 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
Describe global payment as a reimbursement system
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
What defines an “episode of care?”
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
What is the International Consortioum of Health Outcome Measures (ICHOM)?
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
What are “facility” healthcare services?
What kind of insurance covers these services?
- Anything where a “facility” needs to be used
- Hospital stays, skilled nursing stays, outpatient surgery
- Covered by Medicare Part A or private insurance
Why are PROMs (Patient Reported Outcome Measures” important?
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?”
What are the relevant racial differences in CKD
- Cardiometabolic risk factors
- But management of these risk factors is influenced by disparities, so this isn’t purely a “difference”
- APOL1 Mutation
What is the differnece between the MIPS and A-APM quality payment plans?
(Implemented by the MACRA legislation)
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
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
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
What components of value-based payment models will increase our ability to manage population?
- Clinically aligned provider network
- Information management platform
- Care model innovation and enhancements
Which country in the world spends the most money on healthcare, per capita?
United States
The average calcium intake in US adults is…
1-1.2 grams
What is an accountable care organization (ACO)?
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”
What is time-driven activity-based costing (TDABC)?
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
What is longevity matching?
- 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)
What is CMMI?
What do they do?
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
Value-based health care = _______ /_________
Value-based health care =
Outcomes that matter to patients / Total costs of care
How does the region you live in currently impact kidney transplantation?
How will this change by the end of 2020?
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
What percentage of total health care dollars are wasted every year?
30%
(This means that almost 1/3 of the dollars spent on healthcare are not making people healthier)
Outcome measures are needed to know ______
Process measures are needed to know ______
Outcome measures are needed to know what works
Process measures are needed to know what inputs and activities achieved the result
Why have the G1 and G2 alleles of APOL1 been maintained in populations of African descent?
- 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
How does tracking health outcomes support the professionalism of clinicians?
Tracking outcomes gives clinicians feedback about what is working and what isn’t.
Identifying, measuring, and improving outcomes can help to improve clinical practice
What is a racial disparity in health? Give examples
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)
What is a process measure?
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
Who does MACRA/QPP apply to?
Most physicians and advanced practice providers (ex: nurse practitioners) who care for medicare patients
What is the biggest contributor to heatlh care waste?
Unnecessary services
What are the major sources of dietary phosphorous?
- Organic
- Animal products
- Dairy
- Vegetables
- Inorganic
- Additives - Very readily absorbed
- Soda, diet soda
- Flavor enhancers
- Preservatives
- Stabilizers
- Additives - Very readily absorbed
The dollar ammount that it costs for a provider to deliver a health care service is the…
- Cost
- Charge
- Price
- Reimbursement
a. Cost
The KDIGO guidelines recommend ______ grams of sodium intake/day
The KDIGO guidelines recommend <2 grams of sodium intake/day
The dollar amount that a health care provider asks for a service is the…
- Cost
- Charge
- Price
- Reimbursement
b. Charge
Often much higher than the actual cost and reimbursement
Can tolerance be induced to avoid long-term immunosuppression?
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
What are the drivers of the new national kidney allocation policy (2014)?
- 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
What are outcome measures?
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
What is the “quadruple aim” for reforming health delivery and payment?
- Improve quality of outcomes
- Lower the cost of care
- Improve the patient experience
- Improve the physician experience
What factors are accounted for in payment designs for ACOs?
Total cost of care over a year (vs. a benchmark)
Performance on key quality measures
List the kidney distribution priorities
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
The new initiative for “Advancing American Kidney Health” incentivizes which two interventions?
Home dialysis
Preemptive kidney transplant
What is a “health care outcome?”
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
The dollar amount that a patient pays out of pocket for a service is the…
- Cost
- Charge
- Price
- Reimbursement
c. Price
We are trying to move toward a more value-based healthcare system, but we currently have a _______-based healthcare system
We are trying to move toward a more value-based healthcare system, but we currently have a volume -based healthcare system
What is a patient-reported outcome measure (PROM )?
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)
How does measurement of GFR contribute to racial disparities in CKD?
Correction for race in African Americans may underdiagnose CKD at early stages
What principles guide the National Organ Transplant Act?
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
“Fee-for-service” systems incentivize __________
“Fee-for-service” systems incentivize volume
The more services a physician can provide, the more they will be paid - does not incentivize quality
What are the 4 programmatic elements of the MIPS alternative-payment track?
- Quality (45%)
- Cost (15%)
- Improvement activities (15%)
- Promoting interoperability (25%)
Which alleles of APOL1 are more common in African American populations?
Why?
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
What foods have high potassium content?
- 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
Describe the Per Diem Payment reimbursement system
A hospital is paid a bundles fee for all services delivered to a patient in a single day
The average potassium intake for adults in the US is ______ grams
The Average potassium intake for adults in the US is 2.5 grams
List the 6 biggest contributors to health care waste, in order from most to least wasteful
- Unnecessary services
- Excessive administrative costs
- Inefficeint care due to systems errors and failures of coordination
- Prices that are excessively high
- Fraud
- Missed prevention opportunities
What is the National Organ Transplant Act (1984)?
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
The average phosphorus intake for adults in the US is _____ grams
The average phosphorus intake for adults in the US is 1.2-1.7 grams
The dollar amount a third-party payer (ex: insurance) negotiates as payment to the provider is the…
- Cost
- Charge
- Price
- Reimbursement
d. Reimbursement
What factors are driving the changing healthcare landscape?
- 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)
What are the two MACRA/QPP tracks for physician payment?
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
What is MACRA?
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!
Describe capitation as a reimbursement mechanism
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
What is health care waste?
Anything we do in healthcare that doesn’t make people healthier
Ex: Tests, medications, and procedures that are not making people healthier
What is a structure measure?
The materal, human, and organizational resources available in the setting in which care is delivered
Ex: the number of hospital beds, available staff, etc.
The most common cause of kidney transplant (graft) failure is…
- Rejection
- Infection
- Death with functioning graft
- Medication toxicity
C. Death with functioning graft
Whether a pateint with a heart attack is prescribed an ace inihbitor medication prior to discharge is a…
- Process measure
- Outcome measure
- Structural measure
a. Process measure
