The Dialysis Vascular Access Coalition (DVAC) is a coalition of medical specialty societies, physicians, and vascular access centers of excellence (VACs) in the office and ASC setting that provide vascular access services to individuals with advanced chronic kidney disease and End-Stage Renal Disease (ESRD). VACs treat more than half of a million cases per year across the country in a safe, specialized, patient-preferred setting.
Challenges facing out-patient access centers and COVID-19
Most vascular access centers (VACs) operate as physician offices or ambulatory surgical center (ASCs) and are voluntarily accredited by nationally recognized bodies. They are typically reimbursed for services by Medicare under either the Physician Fee Schedule or the Ambulatory Surgical Center Prospective Payment System Fee Schedule.
While non-hospital specialization is positive for Medicare beneficiaries and total program costs, it also makes such providers vulnerable to significant volatility in reimbursement rates given that such providers do not broadly diversify their services as a typical hospital might.
In the 2017 Physician Fee Schedule, the Centers for Medicare & Medicaid Services (CMS) cut payments to a key vascular access code by 39%. A survey by the American Society of Diagnostic and Interventional Nephrology (ASDIN) in 2018 found that reimbursement levels were so inadequate that more than 20 percent of respondents surveyed stated their centers had closed due to the cuts. More recent Medicare claims data has confirmed a decrease in office-based vascular access services of more than 30 percent since 2017.
In the 2018 Ambulatory Surgical Centers (ASC) Fee Schedule, CMS proposed to cut ASC rates for vascular access services down to office-based rates, but later reversed this decision. These actual (PFS) and proposed (ASC) cuts to vascular access centers of excellence have caused major disruptions to ESRD patients.
Unfortunately, the 2022 Physician Fee Schedule finalizes yet another round of huge, 18% cuts to the same key vascular access code that was cut by 39% in 2017. These cuts will cause another round of center closures and further threaten access to dialysis vascular access care.
As the United States fights the COVID-19 pandemic, keeping VACs open means better patient outcomes and more protection for dialysis patients. DVAC believes that the COVID-19 hospital surges underscore the need for office-based providers to remain viable. Policymakers must find ways to provide dialysis patients with safe, community based healthcare services and away from hospital admissions, as they are a particularly vulnerable population.
Payment Stability / Physician Fee Schedule (PFS)
Because non-hospital vascular access centers are specialized centers focused on vascular access care, they cannot diversify across a broad range of services as hospitals may do. As a result, unlike hospitals, significant payment volatility for vascular access centers cannot be offset by increases to other services in Medicare fee schedules.
DVAC strongly supports efforts by the United Specialists for Patient Access and other stakeholders requesting that Congress stop the clinical labor policy contained in the 2022 Physician Fee Schedule (PFS) Final Rule and instead work on fundamental reform of the PFS to ensure that providers do not experience drastic swings in payments year to year.
Fistula Vs. Catheter
The majority of Medicare beneficiaries with ESRD receive dialysis treatments to sustain life. Before patients with ESRD can initiate dialysis treatment, access to their bloodstream is required.
Fistulas are recognized as the best vascular access option for many patients. Conversely, central line catheters have demonstrated high infection rates, high hospitalization rates, and high costs. Compared to fistulas, the average annual total cost of treating patients with catheters is significantly higher ($90,000 for catheters vs. $64,000 for fistulas). Research has shown that fistulas are the gold standard for quality dialysis vascular access for multiple reasons, including lower rates of infection and loss of function due to clotting.
It’s a simple equation: further cuts from CMS will result in fewer patients receiving the gold standard of care.
This article was written by Grant Herring on behalf of the Dialysis Vascular Access Coalition and shared with Vasc-Alert. Vasc-Alert partners with DVAC, sharing research data and providing additional communications support. To learn more about DVAC, please visit https://www.dialysisvascularaccess.org/about.