Journal Departments

Controversies in Nephrology Nursing

Has the CMS Rule of “4 Visits Per Month” Influenced Patient Outcomes?
Christy Price Rabetoy, Department Editor

Increased Frequency of Visits Has Promoted Improved Patient/Provider Relationships
Kathy Ellis, BSN, CNN, MHS
Janet Mueller, CNN-NP
Nephrology Nurse Practitioner
University of Utah, Nephrology Division
Salt Lake City, UT
President, ANNA’s Intermountain Chapter.

In January 2004, the Centers for Medicare and Medicaid Service (CMS) passed new guidelines increasing the physician reimbursement for face-to-face dialysis visits. This created a financial incentive for more frequent visits; the goal being improved patient outcomes. To date, some studies show that increased visits result in achievement of more clinical performance targets (Plantinga et al., 2005). The performance targets from the Kidney Disease Dialysis Outcome Initiatives (KDOQI) guidelines address renal disease care for vascular access, dialysis adequacy, nutrition, anemia, and bone disease management. Recently published studies show that patients on long-term hemodialysis who meet multiple clinical performance measures have decreased hospitalizations and mortality rates (Plantinga et al., 2007; Rocco et al., 2006). The responsibility of frequent face-to-face visits in the dialysis setting is often shared between the nephrologist and nurse practitioners (NP). In many clinical settings, the majority of these visits fall within the realm of the NP. Published studies only cite performance improvements through physician visits, not NP-based visits.

Providing Care to a Growing Population
Annually, the number of patients with ESRD increase by approximately 9%. Delivering care to this ever- expanding population has outpaced the availability of trained nephrologists. With the shortage of nephrologists, collaborative practice between nephrologists and nurse practitioners is becoming commonplace. NPs seeing patients in dialysis units on a weekly basis are on the frontline for improving the quality of care. For these visits to be of maximum benefit to the patient, it is essential to focus on modifiable factors to achieve adequate dialysis dose, maintain optimal vascular access, identify the factors that affect anemia outcomes, and discuss strategies for improving calcium-phosphorus product and nutrition. Meeting performance targets may be one of the true breakthroughs in reducing morbidity and mortality rates and controlling the escalating costs for delivering care to our patients.

How These Performance Guidelines Came About
The mortality and morbidity rates associated with ESRD are a source of grave concern with mortality rates for patients with ESRD approximating 15% to 20% annually. In 1993, the CMS established a program to improve the quality of care for patients receiving dialysis. In 1997, the National Kidney Foundation developed the Dialysis Outcome Quality Initiatives (DOQI) establishing quality of care indicators. Over the past decade, patient survival and quality of life have improved primarily through increasing adequacy of dialysis and management of anemia (Collins, 2002; Owen et al., 1993). Adequate dialysis dose or Kt/V strongly correlate with patient survival and decreased hospitalization, reducing patient care costs (Plantinga et al., 2005).

NPs are positioned to identify the sources of poor dialysis adequacy, whether it is referral for conversion of catheters to permanent vascular access, monitoring failing vascular access, or counseling patients to increase time on dialysis. Common problems can be detected through close patient monitoring. Simple measures such as additional dialysis treatments for fluid overload can be managed in the outpatient clinics, avoiding costly hospitalizations. This is another example of the cost-saving benefits of frequent visits. In a prospective analysis of the global costs for patients on maintenance dialysis, inpatient hospital bed costs are the single most expensive expenditure (Plough et al., 2003).

Not All Parameters For Improved Outcomes Are Quantifiable
Performance indicators are the measurable outcomes of frequent visits. Are improved outcomes purely the result of diligently pouring over monthly numbers generated from lab tests and dialysis records and tweaking dialysis prescriptions and medications? Or could it be the human element – relationships that develop between patient and provider through frequent visits? Often patients view providers in an adversarial rather than a supportive role, challenging their behaviors rather than focusing on the small, but significant, measures they make in their day-to-day struggle to deal with the demands of their disease. Weekly visits promote an environment where trusting partnerships develop, facilitating better communication and opportunities for education and adherence to treatment prescriptions. More frequent visits result in better patient relations.

There are few studies documenting the role NPs play in improving patient outcomes. This is an area ripe for further investigation. It must be noted, that this would be a challenging study to separate out the direct effect of NPs in meeting clinical performance targets as these outcomes require a concerted effort on the part of nephrologists, administrators, pharmacists, nephrology clinical nurses and technicians, and outside providers as well as the NPs. With most patients with ESRD having at least four comorbidities, maintaining a focused visit on performance indicators puts practitioners to the test. Making weekly visits is time well spent if it brings about a reduction in morbidity, mortality, and hospitalizations.

Nephrology Healthcare Providers Should Determine the Frequency of Patient Visits
Kristin Larson, MSN, ANP, GNP
Nephrology Nurse Practitioner
Nephrology Associates, Inc.
Salt Lake City, UT
ANNA Chair Designate/Advisor for CapWiz
Member, ANNA’s Intermountain Chapter.

In January 2004, the Centers for Medicare and Medicaid Services (CMS) replaced the exiting current procedural terminology codes for patients with end stage renal disease (ESRD) receiving dialysis in the outpatient setting. The new system established reimbursement “G codes” for the number of face-to-face patient/provider visits and was intended to improve the care of individuals with renal disease, the concept being that more nephrologist or nurse practitioner (NP) visits would enhance care and outcomes for patients with ESRD. Within these provisions was the acknowledgement of the role of advanced practice nurses and their contributions to patients with ESRD. For this recognition, I was pleased, as most of my practice was, within the outpatient renal community. However, 3 years into the G codes, I ask myself if this rule promotes the best patient care and outcomes, as well as efficiently maximizing my skills as a nephrology NP.

As an NP for a busy private practice group, I perform three of the four monthly visits for 160 patients with ESRD and receiving hemodialysis. I am frustrated by the G code mandates that have been placed on my practice, and I feel am often “checking off boxes” to prove to CMS that I have provided acceptable care. I beg to differ. Some of my patients truly need weekly visits, such as those individuals recently discharged from the hospital who require close monitoring and follow-up. In fact, I may see those patients twice per week, which does not affect CMS reimbursement, nor does the time I spend answering phone calls or pages with patients or families. This activity does not count towards the monthly G code tally.

End stage renal disease is a chronic illness and patients with other life-long diseases such as diabetes, hypertension, or cardiovascular disease are not seen weekly by a provider. Why then does CMS mandate requirements for this population, especially if the visits are nothing more than an informal inquiry of the preceding week’s events? In my role as an NP, I assess and partner with patients to establish a plan of care that promotes optimal health and self-management. The G code shifts the responsibility from patient self-management to dependence of the medial provider to manage all health-related issues, both renal and nonrenal, and perpetuates the belief that dialysis is the beginning of the end for those with Stage 5 CKD. Nurse practitioners assess, plan, and implement based on the needs of the patient. I am able to determine the frequency with which to visit a patient based on these skills and can alter that frequency as my patient needs change. The G codes imply that all patients fit into a “four visits fits all” category, which is not true.

Three years have passed since the implementation of the four visits per month G code. Network data demonstrating the effectiveness of ESRD outcomes pre-2004 should be available for all clinics to review, as well as to determine how clinical markers such as adequacy, bone disease, and anemia have improved or changed (although the definition of optimal anemia management is under the microscope).
In the meantime, I will continue to see my patients and serve them well. I expect CMS to do the same.

The Controversies in Nephrology Nursing department focuses on exploring ethical and clinical issues within the nephrology clinic practice in a point/counterpoint format. Address correspondence to: Christy Price Rabetoy, Department Editor, through the ANNA National Office; East Holly Avenue/Box 56; Pitman, NJ 08071-0056; (856) 256-2320; or by emailing her at christycpr@comcast.net. You may also log onto this column at www.nephrologynursingjournal.net (clink on Department link) and email your comments to the Editor (see Discussion Area). The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of the American Nephrology Nurses' Association.