Thursday, 10 February 2011

Paying for value not volume

Outcomes for people with advanced chronic kidney disease are dependent on meaningful engagement with patients, carers and families and high quality preparation for the chosen modality of renal replacement therapy or conservative kidney care. That needs a committed, skilled and adequately resourced multi-professional team working with “activated” patients.

To support kidney care multi-professional team working new arrangements are been put in place in England for adult services from April 2011. Payment to Trusts for first outpatients visits that are multi-professional will receive a 50% uplift (price for doctors only first visits £198 versus £328 for first MDT visit) with ongoing multi-professional care attracting more than double physician only outpatient attendances (£128 versus £257). These multi-professional outpatient kidney care tariffs are aimed principally at supporting standard 2 and quality requirement 4 of our National Service Framework.

STANDARD TWO: All children, young people and adults approaching established renal failure are to receive timely preparation for renal replacement therapy so the complications and progression of their disease are minimised, and their choice of clinically appropriate treatment options is maximised.

QUALITY REQUIREMENT FOUR: People with established renal failure receive timely evaluation of their prognosis, information about the choices available to them, and for those near the end of life a jointly agreed palliative care plan, built around their individual needs and preferences. People with complex multi-system disorders and those with primary kidney disease or post-transplant receiving high dose immunosuppressive regimes will also be able to benefit from this payment for quality.

People with complex multi system disorders and those with primary kidney disease or post transplant receiving high dose immunosuppressive regimes will also be able to benefit from this payment for quality.

I am confident that the introduction of this payment system for hospitals has the potential to make another step change improvement to the experience and outcomes of care for people with advanced kidney disease and those requiring multi-disciplinary care because of intricate and potentially toxic treatment.

There is a risk of gaming; I think that’s a polite phrase for cheating. Kidney units and Trusts could put a nurse in every clinic and attempt to claim the multi-professional rate for every patient visit. If we do that not only will our patients miss out but we will be found out! Commissioners of kidney care, quite rightly, will not be prepared to pay the premium price to teams who twist the rules for “multi-professional” care that doesn’t add value. What’s more, kidney teams do not have the resources to have a full multi-professional team in every clinic; and we don’t need it.

The multi-professional tariff is not a golden goose – but we could still kill it if we don’t play according to the spirit of the rules. It has been put in place to maintain and improve “preparation and choice”, “conservative kidney care” and safe delivery of “complex immunosuppression”. It should help kidney units target our key resources, our staff, to where we can add most value. Multi-professional clinics should grow allowing more time and support for shared decision making and management resulting in more people receiving pre-emptive transplants, more people receiving peritoneal and home haemodialysis, more people starting haemodialysis via a fistula, better psychological preparation, safer medicines management, fewer complications and less admissions. The flip side is reduction, indeed removal, of no added value clinics for instance for people with stable stage 3 CKD and reduction in inpatient activity and staffing.

Strict interpretation of the rules could equally stifle innovation as well as “break the bank”. Much good multi-professional care is now delivered in patient’s homes or in group sessions – stopping this to bring people in for multi-professional clinics in the outpatients is not in patients’ interests. Commissioners, managers, clinicians and patients need to work together to ensure the model of care achieves the experience and outcomes we all desire and then make the finances fit what the patients want, not the other way around.

The multi-professional tariff has more risk of unintended consequences than the best practice tariff for haemodialysis that will be rewarding dialysis via a fistula from April 2011 but has the potential to be equally effective at leveraging quality if we use it to target our resources and support a different way of working. It will help kidney services navigate a way through the recession, it’s not a way of avoiding the current harsh financial reality facing the public services.

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