Browsing by Author "Wish, Jay"

Now showing 1 - 3 of 3
  • Thumbnail Image
    Item
    The Evolution of Target Hemoglobin Levels in Anemia of Chronic Kidney Disease
    (Elsevier, 2019-07) Bazely, Jonathan; Wish, Jay; Medicine, School of Medicine
    Since the introduction of erythropoiesis-stimulating agents (ESAs) into clinical practice in 1989, considerable effort has been put forth toward identifying the optimal treatment strategy for managing anemia of CKD. After initial treatment of only the most severely anemic patients, therapy was subsequently expanded to include most patients on dialysis and many nondialysis CKD patients. Many nephrology societies and regulatory agencies have sought to identify the most appropriate hemoglobin levels to which ESA therapy should be targeted. As increasing evidence became available about the impacts of ESAs on varying endpoints including morbidity, mortality, and quality of life, the guidelines put forth by such agencies evolved over time. We review the literature impacting these determinations through the past 3 decades and comment on how this informs the application of this knowledge to the care of patients today.
  • Thumbnail Image
    Item
    A Patient-Centered Approach to Hemodialysis Vascular Access in the Era of Fistula First
    (Wiley, 2016-03) Kalloo, Sean; Blake, Peter G.; Wish, Jay; Department of Medicine, IU School of Medicine
    The primary vascular access options for the hemodialysis population are arteriovenous fistulas (AVF), arteriovenous grafts, and cuffed central venous catheters (CVC). AVFs are associated with the most favorable outcomes with respect to complications, interventions required to maintain functionality and patency, and overall cost. These population-based outcomes, in conjunction with the efforts of the Fistula First Breakthrough Initiative, have propelled the prevalence of AVFs in the US hemodialysis population. While this endeavor remains steadfast in assuring the continued dominance of this policy for AVF preference, it fails to take into account a subset of the dialysis population who will fail to see the benefits of an AVF. This subset of patients may include the elderly, those with poor vasculature anatomy, those with slowly progressive CKD who are more likely to die than progress to ESRD, and those with an overall poor long-term prognosis and shortened life expectancy. Thus, in an effort to avoid numerous unnecessary surgical and interventional procedures with minimal to no gains in clinical outcomes, an individualized patient approach must be adopted. The Centers for Medicare and Medicaid Services–instituted quality incentive program is designed to reward high AVF prevalence while also penalizing high CVC prevalence. The current model is devoid of case-based adjustment, thus penalties are disbursed to dialysis providers in accordance with a “one-size-fits-all” fistula only approach. The most suitable access for a patient remains the one that takes into account the characteristics unique to the individual patient with a primary focus on patient comfort, satisfaction, quality of life, and clinical outcomes.
  • Thumbnail Image
    Item
    Rebasing the Medicare payment for dialysis: rationale, challenges, and opportunities
    (American Society of Nephrology (ASN), 2014-12-05) Wish, Diane; Johnson, Doug; Wish, Jay; Department of Medicine, IU School of Medicine
    After Medicare's implementation of the bundled payment for dialysis in 2011, there has been a predictable decrease in the use of intravenous drugs included in the bundle. The change in use of erythropoiesis-stimulating agents, which decreased by 37% between 2007, when its allowance in the bundle was calculated, and 2012, was because of both changes in the Food and Drug Administration labeling for erythropoiesis-stimulating agents in 2011 and cost-containment efforts at the facility level. Legislation in 2012 required Medicare to decrease (rebase) the bundled payment for dialysis in 2014 to reflect this decrease in intravenous drug use, which amounted to a cut of 12% or $30 per treatment. Medicare subsequently decided to phase in this decrease in payment over several years to offset the increase in dialysis payment that would otherwise have occurred with inflation. A 3% reduction from the rebasing would offset an approximately 3% increase in the market basket that determines a facility's costs for 2014 and 2015. Legislation in March of 2014 provides that the rebasing will result in a 1.25% decrease in the market basket adjustment in 2016 and 2017 and a 1% decrease in the market basket adjustment in 2018 for an aggregate rebasing of 9.5% spread over 5 years. Adjusting to this payment decrease in inflation-adjusted dollars will be challenging for many dialysis providers in an industry that operates at an average 3%-4% margin. Closure of facilities, decreases in services, and increased consolidation of the industry are possible scenarios. Newer models of reimbursement, such as ESRD seamless care organizations, offer dialysis providers the opportunity to align incentives between themselves, nephrologists, hospitals, and other health care providers, potentially improving outcomes and saving money, which will be shared between Medicare and the participating providers.