Mentari EK et al. (2005) Changes in Medicare reimbursement and patient-nephrologist visits, quality of care, and health-related quality of life. Am J Kidney Dis 46: 621–627

In 2004, the way in which MEDICARE reimburses nephrologists for the care of dialysis patients was redesigned to boost the frequency of patient–nephrologist interactions. A retrospective analysis of records at 12 dialysis facilities in Ohio indicates that the changes might so far have failed to improve patient care.

The study included all in-center hemodialysis patients who were treated for at least 6 months immediately before and after implementation of the new reimbursement system (n = 1,600). The mean number of nephrologist visits (both office and on rounds) per patient-month sharply increased following the policy change (1.52 before vs 3.14 after; P < 0.001). Despite this increase, there was no clinically significant improvement in most indicators of quality of care, including catheter use, ultrafiltration volume and number of hospital admissions. The reforms had no impact on health-related quality of life, as determined by a validated patient questionnaire (n = 500) assessing variables such as vitality, bodily pain, social functioning and mental health. Even the outcomes of individuals who had the least-frequent contact with nephrologists at baseline (n = 136) did not improve.

These findings might not be accurate when extrapolated to the US as a whole, and longer follow-up is needed to track the effects of the policy change over the long term. Nevertheless, it is concerning that the new system might be an inefficient use of physician resources. The authors propose reimbursement based directly on outcomes, rather than frequency of consultation, as an alternative.