Proposed Cuts to Vascular Access Care Cut Too Deep

With one in 10 Americans suffering from kidney disease — including 15 million who have no clue that they are afflicted — we are in the midst of a public health crisis. Often caused by diabetes and high blood pressure, kidney disease is an overlooked epidemic.

Despite this, the Centers for Medicare and Medicaid Services has unveiled a rule that would slash payments for dialysis vascular access services. This is the surgery that creates access points on a kidney patient’s body, permitting a dialysis machine to connect and filter the patient’s blood. Without a vascular access point, dialysis cannot be performed.

Over a decade ago, CMS initiated a program called Fistula First to encourage the placement of arteriovenous fistulas as access sites for dialysis. Fistulas are a much safer alternative to catheters, which are infection-prone. Infections from catheters not only threaten the well-being of dialysis patients but also impose the costs of complications on the Medicare program.

It is in the interests of both kidney patients and the Medicare Trust Fund that there be easy availability of vascular surgeons to create fistulas in incident end-stage renal disease patients — ideally before a patient experiences complete kidney failure — and immediate availability of vascular surgeons when a fistula needs repair.

ESRD patients are the least stable, and the most costly, in the immediate aftermath of kidney failure. Placement of a fistula in incident patients is considered a best practice, and important work has been underway to develop quality measures and new payment models (including one endorsed by the PTAC) to incentivize timely referral of such patients to vascular surgeons.

ESRD patients also face a potential cascade of complications when a fistula is blocked and needs repair. Earlier this year, we met a dialysis patient who, while away from home on vacation, experienced a blocked fistula. Due to delays in providing care at a hospital emergency department, her dialysis treatments were delayed, and she suffered the loss of eyesight in one eye and amputation of a foot.

As the importance of fistulas became more widely recognized, non-hospital vascular access centers developed in the physician office and ambulatory surgery center settings to meet clinical demand. Recent data show that patients who receive vascular access care in an office setting exhibit 20 percent fewer infections, require 14 percent fewer hospitalizations, and have 15 percent lower annual mortality rates than when vascular access services are provided in the hospital.

In recent years, mortality and morbidity in the ESRD population has decreased, in no small part due to improved vascular access care. Unfortunately, the ASC proposed rule threatens to cut reimbursement to vascular access centers by 62 percent. If history is any guide, these cuts would squeeze vascular access providers out of communities that need them most. When CMS implemented a 39 percent reduction in reimbursement rates in 2017, a large number of vascular access centers were forced to close their doors.

By forcing vascular access providers out of communities, CMS’ proposed cuts will leave ESRD patients with fewer options, likely placing dialysis patients in the costlier hospital setting for vascular access procedures, again exposing them to lower-quality care, procedure delays and dangerous infections.

Fortunately, bipartisan members of Congress are taking notice of this crisis. Representatives Ryan Costello (R-Pa.), Debbie Dingell (D-Mich.) and Leonard Lance (R-N.J.) are leading an effort in Congress to ensure these proposed cuts are excluded from the final ASC payment rule for 2019. I hope other members of Congress will recognize the health risks these proposed cuts have on their constituents in need of dialysis care to manage their kidney disease.

It is critical that Congress urge Medicare to protect access to high-quality vascular access services by removing these cuts from the final rule so the kidney care community can build on the gains of the last two decades.


Hrant Jamgochian is chief executive officer of Dialysis Patient Citizens, a nationwide, nonprofit, patient-led organization with membership open only to dialysis and pre-dialysis patients and their families.

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