Medicare Hospice may limit access to concurrent hospice, dialysis among veterans with ESKD

November 23, 2022

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Veterans with end-stage renal disease who received hospice funded by the Veterans Health Administration were more likely to receive concomitant treatment than those who received hospice funded by Medicare, according to recently published data.

Furthermore, researchers suggest that Medicare hospital policies may severely limit access to concurrent hospital and dialysis services among this population.

Infographic showing the percentage of veterans with ESKD with a VA-funded hospital

Data were obtained from Wachterman MW, et al. JAMA Health Forum. 2022; doi:10.1001/jamahealthforum.2022.3708.

“Because most patients with ESKD are eligible for Medicare at any age, many Veterans enrolled in the VA have the option of receiving hospital care under either their VA or Medicare benefits. In the context of VA’s more liberal approach to hospice eligibility and payment, comparative patterns of concurrent care among veterans with ESKD receiving hospice care under Medicare vs. VA may be informative,” Melissa W. WachtermanMD, MSc, MPH, from the Division of General Internal Medicine at Veteran Affairs Boston Health Care System, and colleagues wrote. “This study compared rates of concurrent dialysis and hospital use among a group of veterans receiving maintenance dialysis for ESKD and examined which hospital payers funded dialysis treatments after hospital initiation.”

In a retrospective cross-sectional study, researchers examined rates of concurrent hospital and dialysis treatment among all 70,577 VA enrollees with ESKD in the US Renal Data System Registry who initiated maintenance dialysis and died between 2007 and 2016. Researchers wondered whether rates of treatment differed by hospital payer, including Medicare, VA inpatient or VA-funded community hospitals.

A total of 18,420 veterans with ESKD received hospital care. However, 89% received physical therapy under Medicare, and 28% continued to receive dialysis after starting treatment. The researchers noted an increase in the adjusted proportion of veterans receiving concurrent care among those enrolled in VA inpatient or VA community settings than among those enrolled in Medicare hospice. Furthermore, 87% of all posthospitalization treatments, regardless of hospital payer, were funded by the VA.

“Our findings in the elderly population highlight the importance of several ongoing efforts by the Center for Medicare & Medicaid Innovation (CMMI) to explore the feasibility of offering concurrent hospital and dialysis services under the Medicare program.” In 2020, CMMI created the Kidney Care Choices Model, a value-based payment model in which dialysis facilities, nephrologists and other Medicare physicians can participate in establishing kidney contracts (KCEs) to provide care within an accountable care framework,” Wachterman and colleagues wrote. They added, “If any KCE chooses to offer concurrent care, the initiative may offer a unique opportunity to examine the quality and cost of concurrent care among Medicare beneficiaries and to understand how its provision shapes patient experience and end-of-life care.” with ESKD and their families.”

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