Dialysis Reimbursement: What Impact Do Different Models Have on Clinical Choices?

Autor: Piccoli GB; Department of Clinical and Biological Sciences, University of Torino Italy, 10100 Torino, Italy. gbpiccoli@yahoo.it.; Nephrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France. gbpiccoli@yahoo.it., Cabiddu G; Nephrology, Brotzu Hospital, 09100 Cagliari, Italy. gianfranca.cabiddu@tin.it., Breuer C; Direction, Centre Hospitalier Le Mans, 72000 Le Mans, France. cbreuer@ch-lemans.fr., Jadeau C; Centre de Recherche Clinique, Centre Hospitalier Le Mans, 72000 Le Mans, France. cjadeau@ch-lemans.fr., Testa A; Association ECHO, 44000 Nantes, France. atesta@echo-sante.com., Brunori G; Nefrologia, Ospedale di Trento, 38100 Trento, Italy. gcbrunori@hotmail.com.
Jazyk: angličtina
Zdroj: Journal of clinical medicine [J Clin Med] 2019 Feb 25; Vol. 8 (2). Date of Electronic Publication: 2019 Feb 25.
DOI: 10.3390/jcm8020276
Abstrakt: Allowing patients to live for decades without the function of a vital organ is a medical miracle, but one that is not without cost both in terms of morbidity and quality of life and in economic terms. Renal replacement therapy (RRT) consumes between 2% and 5% of the overall health care expenditure in countries where dialysis is available without restrictions. While transplantation is the preferred treatment in patients without contraindications, old age and comorbidity limit its indications, and low organ availability may result in long waiting times. As a consequence, 30⁻70% of the patients depend on dialysis, which remains the main determinant of the cost of RRT. Costs of dialysis are differently defined, and its reimbursement follows different rules. There are three main ways of establishing dialysis reimbursement. The first involves dividing dialysis into a series of elements and reimbursing each one separately (dialysis itself, medications, drugs, transportation, hospitalisation, etc.). The second, known as the capitation system, consists of merging these elements in a per capita reimbursement, while the third, usually called the bundle system, entails identifying a core of procedures intrinsically linked to treatment (e.g., dialysis sessions, tests, intradialyitc drugs). Each one has advantages and drawbacks, and impacts differently on the organization and delivery of care: payment per session may favour fragmentation and make a global appraisal difficult; a correct capitation system needs a careful correction for comorbidity, and may exacerbate competition between public and private settings, the latter aiming at selecting the least complex cases; a bundle system, in which the main elements linked to the dialysis sessions are considered together, may be a good compromise but risks penalising complex patients, and requires a rapid adaptation to treatment changes. Retarding dialysis is a clinical and economical goal, but the incentives for predialysis care are not established and its development may be unfavourable for the provider. A closer cooperation between policymakers, economists and nephrologists is needed to ensure a high quality of dialysis care.
Databáze: MEDLINE
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