Beginning in 2007, vascular access reimbursement rates have experienced significant reduction with more proposed in 2010. Many vascular access center owners are concerned about their ability to continue to treat patients in this reimbursement environment. This begs the question, “What should operators do now to survive future reimbursement reductions?”

The closure of vascular access centers due to reimbursement reductions is not a desirable outcome. Freestanding access centers provide convenient high quality care at costs lower than hospital. With a focus on fistulas, these centers serve an important role in salvaging and maintaining fistulas. In order to meet Kidney Disease Outcomes Quality Initiatives (KDOQI) guidelines and the Centers for Medicare & Medicaid Services (CMS) stretch goal of increasing the percentage of hemodialysis patients using fistulas to 66 percent by 2009, it is important that the maximum number of fistulas be created. Early failure, or failure of the newly created fistula to develop adequately for use, has always been a problem. As efforts to create more fistulas have intensified, it appears that the incidence of early failure has increased. In fact, the medical literature indicates that 20-50 percent of fistulas that are created never function, or fail within a very short period. These failed fistulas can be treated with a high expectation of success. This treatment is often performed at vascular access centers. Freestanding access centers play an important role in promoting fistulas and fistula prevalence has increased as the number of access centers has increased.

Access centers play an important role in kidney care and their continued presence in the kidney care value chain is important. The reality, however, is that all payers are looking for ways to reduce costs. There are several things vascular access centers need to do to protect their ability to continue to provide valuable services to their patients: Centers that will thrive must have superior cost structures, and the industry as a whole will need exceptional stakeholder engagement and support.

Superior Cost Structure, Operational Efficiency

The high performance vascular access center of the future must have a lean cost structure and high operational efficiency. In the current economic climate the mention of lean costs immediately leads to visions of staff reductions. Optimal clinical staffing is always important, however there are three other things to consider. None of these three items involve staff cuts, but focus instead on getting the most out of a practice with the available resources.

Case Costing and Inventory Optimization

The first step to inventory optimization is to make sure that one is in the best buying group and getting the best value from its vendors. The next step is to track inventory at both a macro and micro level. At the macro level, centers should perform an assessment of historic inventory usage to identify items that they can afford to carry in lower quantities in order to reduce the amount of capital locked up in inventory. At the micro level, centers should perform procedure case costing to determine actual supply costs for cases. Knowing how much the center is spending per case type per physician is just the beginning. The next step is to compare this against an industry benchmark or best practice and then identify supply alternatives that deliver high quality outcomes at a lower cost.

Last year, Lifeline Vascular Access, a DaVita subsidiary and the nation’s largest vascular access management service company, rolled out a new inventory management system for its managed centers. Using this technology the company is helping its managed centers identify opportunities to improve their case costing and optimize their inventory. Lifeline Vascular Access managed centers have collectively experienced over 250,000 patient encounters. This database of encounters is invaluable in helping centers benchmark their performance and identify ways to improve their case costing by optimizing inventory decisions without compromising their high standard of care. Not all vascular access centers have the opportunity to benefit from a network of providers. For these centers critical focus on supply utilization will usually reveal areas for improvement.

Improved Patient Scheduling...and Patient Satisfaction

Patient scheduling is both an art and a science. The goal of patient scheduling, on one hand, is to provide convenient care to patients with minimum wait-times. On the other hand, the goal of patient scheduling is to provide staff with sufficient time to treat their patients with minimum down-time between patient procedures. The average time it takes to perform a procedure is at the heart of this equation. Rather than scheduling patients into one-hour time blocks, which is the default option in many scheduling software, center coordinators should look at the average time it takes for each procedure to be performed and schedule patients accordingly. Even within a center, two different physicians may have different average times. So it is helpful to look at individual physician procedure times and use this as the procedure time block when scheduling patients. This will allow the center to accomplish its goals of minimum patient wait-time, sufficient procedure-time allocations, and minimum resource downtime.

The above assumes there is a constant flow of patients every day. This may not be the case for many centers with patients not showing up or canceling their appointments at the last minute. No-shows and cancellations reduce a center’s revenue per day while overhead stays the same. Lifeline Vascular Access data shows that there is an inverse correlation between patient satisfaction scores and patient no-shows or cancellations levels. Patient satisfaction with a center influences whether they will return or seek treatment elsewhere. Lifeline Vascular Access conducts patient satisfaction surveys for all of its managed centers. Being able to see where patients are dissatisfied and then taking corrective action, like in any other service industry, is important for continued “customer” loyalty. This, however, is a longer term strategy for reducing patient no-shows and cancellations. A more immediate approach is to have a proactive patient reminder system, for example, calling 24-48 hours in advance of an appointment to confirm.

Space Sharing with Other Nephrologists, Interventional Radiologists and Surgeons

Smaller vascular access centers at risk of going out of business may consider a “consolidation strategy” in which they share their vascular access center space with another practice or bring in other specialists who can leverage their existing infrastructure and staff. Forming relationships such as these will allow the center to keep its staff optimized by serving a wider patient base.

Exceptional Stakeholder Support and Engagement

There are two stakeholders who determine the success or failure of vascular access centers—providers and payers. On the provider side, the importance of support from nephrologists for vascular access care is well known. Nephrologists send their patients to centers that provide the highest quality, most convenient care to their patients. Preferred vascular access centers are those centers that provide timely appropriate care coordination and feedback after each patient encounter. For vascular access centers that depend on patient flow from community nephrologists, demonstrated quality of care and provider satisfaction is of the utmost importance.

Payer support is also extremely important, but often not explored. For this discussion the focus is on how to get the support of the largest payer in the area of vascular access care—the Centers for Medicare & Medicaid Services—through positive engagement, and proper coding and documentation.

Positive Engagement with CMS

Positive engagement and support from CMS is important for the continued improvement and success of vascular access centers as demonstrated by recent events.

In April 2008, CMS proposed a NCCI (National Correct Coding Initiative) edit, which would (1) bundle specific vascular access angioplasty codes, (2) allow only one code to be used for angioplasties within an access regardless of how many procedures were performed and (3) redefine the definition of a vascular access site.

This edit would have resulted in significant reimbursement reduction that would have forced some vascular access centers to close, threatening the availability of needed vascular access care to patients. In an effort to ensure continued patient accessibility to vascular access care, Lifeline Vascular Access created a coalition of renal stakeholders, including the American Society of Diagnostic and Interventional Nephrology, American Association of Kidney Patients, Arizona Kidney Disease & Hypertension Center, Kidney Care Partners, Renal Physicians Association, and American Access Care to engage CMS to reconsider the proposed edit.

The coalition was granted an audience with CMS to discuss the complexities of access care especially in a fistula first environment. On April 6, CMS implemented a revised NCCI edit—different from the one proposed. The edit, as implemented, was a significant win for the patient, CMS, and caregivers. The revised edit includes the controls that CMS intended to ensure appropriate coding and reimbursement without having the adverse impact of restricting medically necessary procedures.

The lesson from the success of the NCCI Edit Coalition is that CMS is not blindly making changes. CMS is open to positive engagement as it carefully considers codes and works to improve coding appropriateness without jeopardizing the quality of patient care. Vascular access care providers are encouraged to pursue positive dialogue with CMS in order to ensure that CMS well understands what they do and the tremendous value of their services. Letter writing on issues is one way to engage CMS and is highly encouraged. In March, several physicians from access centers wrote to CMS asking for a revision to the proposed edit and explained why revisions were necessary. Another way to pursue positive engagement with CMS is to appropriately arrange in advance for local legislators or CMS officials to visit the access center and meet with staff and patients who are willing to engage on the topic in order to get a better appreciation of the care provided at a vascular access center.

Proper Coding and Documentation

Vascular access care providers need to demonstrate that their coding practices adhere to coding guidelines. Physicians should make sure their billing team is well informed and that only properly coded bills are sent to CMS for reimbursement. All bills should be reviewed by certified coders who will send incomplete or improperly coded bills back to the physician for clarification, completion or correction before submitting them to CMS. Physicians should make sure that their coding and billing team functions in some manner as an internal auditor serving to complete an initial screening process of claims to be submitted to payers.

Conclusion

In order to survive continued reimbursement pressures, vascular access care providers are encouraged to engage on an individual level with their contracted payers to address proposed coding policy and reimbursement changes. Each individual effort counts toward the collective goal of ensuring continued patient access to high quality lower-cost care.

On a broader scale, the renal stakeholder coalition’s success in establishing a productive dialogue with CMS, confirms that freestanding vascular access centers can effectively collaborate with government payers to address future vascular access reimbursement and coding policies in the interest of continued patient access to high quality, lower cost vascular access care. The future will have continued reimbursement pressure and the centers that will do the best will be those that have a solid handle on their cost structures and operational efficiencies. RBT

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Samuel Awuah, is the vice president of marketing and strategy for Vernon Hills, Ill.-based Lifeline Vascular Access, a DaVita subsidiary. Awuah has an MBA from Amos Tuck School of Business, Dartmouth College, and a BSc in Engineering from Swarthmore College. He has several years of consulting experience across multiple industries, including healthcare and telecommunications. He can be reached at (847) 388-2043.