Снижение выплат Medicare угрожает существованию центров сосудистого доступа и жизни пациентов на диализе

Patients cannot afford to lose community-based vascular access care Key takeaways: - Fistulas are the gold standard for dialysis vascular access, yet 25% of patients on dialysis use catheters. - Community-based vascular access centers increase fistula rates but are threatened by low reimbursement. Recently, a patient on dialysis came to see me who had not been able to receive treatment in 3 weeks. He had shown up to a hospital for a routine vascular access procedure, been placed on a table and then bumped for something more urgent. Nobody called to reschedule. Nobody followed up. He simply fell through the cracks. Until the patient found my clinic, he had gone without dialysis for 3 weeks, which could have led to his death from renal failure. As an interventional nephrologist in Memphis, Tennessee, I treat patients with end-stage kidney disease every day. These patients are among the most medically vulnerable people in America, and in communities like mine, they are disproportionately represented by racial and ethnic minority groups, who develop kidney failure at significantly higher rates than the general population. Patients with ESKD require lifesaving dialysis three times per week or they will die. They also depend on functioning vascular access for such dialysis, and fistulas, not catheters, remain the gold standard for dialysis vascular access. The Healthy People 2030 initiative, a roadmap for national health improvement developed by the HHS, sets a clear target for chronic kidney disease: Reduce the proportion of adult patients on dialysis relying on catheters to no more than 10%. Unfortunately, today catheter rates stand at 25% nationally. The consequences are not abstract: Catheters carry infection rates nearly 20 times higher than fistulas. When we close community-based vascular access centers that create fistulas, patients pay the price. In a hospital setting, patients on dialysis compete with trauma cases and surgical emergencies for time on the schedule. The result, too often, is an emergency catheter instead of a repaired fistula, which trades a short-term solution for a long-term risk. Office-based and ambulatory surgical center vascular access centers exist precisely because this population needs a different kind of care. United States Renal Data System (USRDS) data from 2019 to 2021 confirm what clinicians already know: Patients treated outside of hospitals had statistically significant more fistulas (7.9% more) and fewer central venous catheters (9.8% fewer), along with lower rates of infection, reduced mortality and lower overall costs, resulting in an estimated $10,382 less per patient per year. Yet despite this evidence, the financial foundation beneath these centers has been eroding for years. USRDS data also show that reimbursement, which was cut by nearly 40% for some vascular access procedures in 2017, led to closure of more than 20% of vascular access centers. This wave of closures, which likely limited capacity to perform vascular access procedures, presumably contributed to the increased percentage of patients with a catheter from 2017 to 2022. In the office setting, key reimbursement rates are currently about 20% of what hospitals receive for the same services. In vascular access centers, rates are less than half of hospital rates. By aligning Medicare payment more fairly across office, vascular access center and hospital settings, policymakers can help ensure that vascular access centers remain open in the communities where patients on dialysis live, preventing travel burdens, disruptions in care and the relentless drift toward catheters that the data show follows every clinic closure. Ultimately, the path to achieving the goals of Healthy People 2030 runs through community-based vascular access centers and the specialists who know these patients and can act quickly when something goes wrong. Community-based vascular access centers are the front line of kidney care for some of the most vulnerable patients in America. Congress must stabilize Medicare reimbursement for vascular access centers so we can protect them and the patients they serve. For more information: Omar Davis, MD, an interventional nephrologist in Memphis, Tennessee, worked at Bluff City Vascular until the practice closed in July. He can be reached at [email protected].