TERRY GROSS, host:
After talking with journalist Robin Fields about her investigation into the quality of care at dialysis centers and the costs of treatment, we called Dr. Barry Straube. He's the chief medical officer of the Centers for Medicare and Medicaid Services and director of the Office of Clinical Standards and Quality for Medicare and Medicaid.
Medicare pays for dialysis and related drugs for patients with kidney failure and enforces quality standards at dialysis centers. Robin Fields describes this program as the nation's most ambitious experiment in universal health care.
Dr. Straube, welcome to FRESH AIR. So let me just recap something that Robin Fields says in her article. She says that although some clinics are orderly and expert, others are run like factories. At some clinics, blood is encrusted in the folds of patients' treatment chairs or spattered on the walls, floors or ceiling tiles. Hundreds of clinics have been cited for infection control breaches that expose patients to hepatitis, staph, TB, and HIV. And she says clinics are supposed to be inspected once every three years on average, but as of October, almost one in 10 hadn't had a top to bottom check in at least five years.
What's your assessment of the inspection problem?
Dr. BARRY STRAUBE (Chief Medical Officer, Centers for Medicare and Medicaid Services): Terry, thank you very much for having me on the program today. I think my initial reaction, and I have just skimmed the article, so I haven't been able to analyze it in depth. There definitely is truth in the fact that CMS in its regulatory role overseeing the quality of care in dialysis facilities has not been able to perform as many surveys and therefore, perform that type of oversight as well as it might like to have.
We are hindered by funding that comes from Congress in order to perform regulatory oversight visits for all of the 17 different provider sites that CMS is charged with regulating and overseeing the quality of care. And the funding that is provided to the agency on one hand, is insufficient to be able to meet the statutory requirements in terms of frequency and thoroughness of those site visits.
This is further complicated by the fact that several years ago, many on the Hill felt that we needed to pay more attention to nursing homes than the other types of facilities, including dialysis units. So we were instructed and had to focus with annual visits to all nursing homes at the expense of other facilities and dialysis facilities were, in fact, put on a lower priority track because of that sentiment from the Hill and the funding needs. So we have been not able to perform the oversight functions as frequently or as thoroughly as we might like to.
GROSS: Do you agree with Robin Fields' assessments of the sanitary problems and, you know, infection problems at many of these dialysis clinics?
Dr. STRAUBE: I believe that Robin's article, although pointing up some very important issues that this agency and the Department of Health and Human Services is aware of and trying its best to fix, that it overstates significantly the degree of the problem out in the real world. It makes it sound like any dialysis unit that a patient would walk into is subject to these problems and that's simply not true. The vast, vast majority of the units are not as described in the several examples, which are completely true examples but not illustrative of most dialysis units.
I think my main quibble with the article is that it sounds as though one would not want to have dialysis in the United States. This is a life-saving treatment that the vast majority of people are being treated very well in very clean facilities that hopefully make very few mistakes. And the examples there are not indicative of most dialysis units.
GROSS: One of Robin Fields' criticisms in her investigative article about dialysis centers is that they're largely run by techs, technicians, and that the centers are legally required to have at least one nurse on the premises, and a doctor has to serve as medical director, but the doctor doesn't have to be on the premises all the time. So if something goes wrong, if there's a medical emergency, she says there isn't necessarily going to be the medical staff to take care of it.
Dr. STRAUBE: Well, I think that over time there has been a tendency to using fewer number of nurses and also using more technicians. This is not necessarily a compromise in the quality of care, because the technicians are extremely well-trained and the services that need to be performed for most aspects of the dialysis treatment are quite routine and certainly within the competence and skill set of a well-trained technician.
The fact that there are registered nurses on site, they also are well-trained in terms of emergency interventions, et cetera. Historically, there have not been doctors on-site full-time in any dialysis units for the most part. There may be exceptions where hospital-based units and others may have had an on-site medical physician. But generally, since the inception of the program, that has not been done, so I think the absence of an M.D. does not necessarily compromise the quality of care in the acute setting also.
GROSS: So I know that some of the payment system is about to change, but Robin Fields, in her article about dialysis centers, writes that until now the payment system had a couple of perverse incentives. For example, the government has allowed clinics to bill Medicare separately for certain medications, reimbursing them at a markup over what they paid the drug makers. So she said, the doctors at clinics started prescribing more drugs for problems like anemia and dialysis ended up becoming like the loss leader that got patients in the door so that the clinics could sell drugs at a markup. So that's going to be changed as of next year.
But I'm wondering what you've learned about incentives and pricing that, you know, lessons learned from what you've witnessed.
Dr. STRAUBE: I think, Terry, we've learned, across the Medicare program, that the fee-for-service system provides perverse incentives. We, under fee-for-service, pay the more people do something or the more drug or service they provide, so that the agency for all payment systems is starting to revise those systems to incentivize higher quality care and to try to make the process more efficient.
GROSS: How is it going to be changed in terms of the dialysis centers?
Dr. STRAUBE: Again, as you described before, we were paying a base fee for the standard traditional dialysis services. But over the years, additional very expensive drugs were added to the treatment regiment and these were paid for separately, and with a fairly significant profit margin, if you will. Now we're going to take all of the services and all of the drugs, bundle it into a so-called bundled payment so there'll be one payment that we determine is a reasonable amount of money for an average dialysis facility to be able to provide good care, and it will be up to the dialysis facilities to keep within that budget and provide care for that amount of money or less. And they won't be able to over-prescribe drugs or over-prescribe treatments because they won't be paid for those like before.
GROSS: Is there a danger that they are going to under-prescribe drugs because they'll save money that way, since there is just a standard fee that they're getting, no matter what the treatment is?
Dr. STRAUBE: Yes. There's definitely that and we're very concerned about that. So that in devising the bundled payment system that I described, we have monitoring metrics that would be looking for underprescription of either drugs and/or underutilization of the dialysis services, such as using too short a dialysis time. We'll be monitoring for that and when we identify divergence for either underutilization or other quality of care concerns, we will be taking investigative undertakings to see what's going on.
In addition, we are charged in 2012 with starting an end-stage renal disease quality improvement or quality incentive program, where we give - we are actually going to be able to reduce up to two percent of the dialysis units reimbursement, based on whether or not they provide certain services to meet certain quality metrics. And among those are a number of metrics that we've proposed in the first year, that in fact look at situations where they might underprescribe. So it's looking at anemia management, which is largely dependent on a very expensive drug called Epogen, and we're also going to be looking at dialysis adequacy measures, so that if they're not dialyzing people a long enough period of time, that would show up on those measures. And if they don't meet the prescribed metrics we will be withholding some of their payment as a penalty.
GROSS: Robin Fields in her article says that we pay more per dialysis patient in America than in other Western countries - in other industrialized countries. And yet, our mortality rate for patients on dialysis is higher. How do you explain that?
Dr. STRAUBE: Well, I think that's consistent with the fact that for all medical services in the United States we pay far more per capita than other developed countries in the health care world. And I think that's just indicative that in spite of efforts for the last decade to try to provide medicine and health care more efficiently, we're still haven't succeeded. There's still a tremendous amount of waste in the system where services that are not necessary are being provided. Services that are more costly than others of equal benefit are being provided, and any number of other reasons. So this is consistent with the entire U.S. health care system.
I think, again, our payment reform proposal - well, the bundled payment reform that we're implementing January 1st is going to go a long way towards addressing that issue, because providers will now have a very strong incentive to look at what they're providing and not spend money endlessly but, in fact, to look at their expenditures and only give care that is absolutely necessary, while avoiding negative effects and worsening care in doing so. So they are going to have to walk that tightrope and that balance.
GROSS: Dr. Straube, thank you so much for talking with us.
Dr. STRAUBE: You're quite welcome and thank you for having us on your show.
GROSS: Dr. Barry Straube is the chief medical officer of the Centers for Medicare and Medicaid Services.
You can find links to Robin Fields' article investigating the quality of care at dialysis centers and the cost of treatment on our website, freshair.npr.org.
Coming up, David Bianculli reviews last night's premiere of Conan O'Brien's new show on TBS.
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