Table 1.

Recommended changes in Medicare reimbursement for hemodialysis vascular access management

Earlier disbursement of Medicare benefits to uninsured patients requiring fistula placement
    Uninsured individuals with CKD before requiring hemodialysis: provide payment for surgical and radiological procedures necessary for the creation of hemodialysis fistulas, as well as surgical and radiologic modifications necessary to achieve fistula maturation during the pre-dialysis period for uninsured CKD patients ho ultimately would qualify for Medicare coverage once they have initiated hemodialysis. In patients whose hemodialysis fistula has failed despite appropriate interventions or those patients deemed to be unsuitable candidates for fistula creation, Medicare will provide reimbursement for hemodialysis graft procedures.
    Uninsured new ESRD patients within the first 90 days of hemodialysis: for uninsured new hemodialysis patients who initiate hemodialysis with a catheter only, and who would be eligible for Medicare coverage at 90 days after initiating hemodialysis, provide immediate payment for surgical and radiological procedures necessary for the creation of native arteriovenous fistula, as well as surgical and radiologic modifications necessary to achieve fistula maturation. In patients whose hemodialysis fistulas have failed despite appropriate interventions or those patients deemed unsuitable candidates for fistula creation, Medicare will provide reimbursement for hemodialysis graft procedures.
    Incentives for achieving a mature, functional fistula in new hemodialysis patients: new uninsured hemodialysis patients who initiate hemodialysis with a fistula or whose fistula is successfully used for dialysis before the first 90 days of dialysis with catheter removal, would qualify for immediate, full Medicare coverage during the first 90 days of dialysis, similar to the benefit currently available for those patients who begin a period of home dialysis training prior to the end of the 90-day waiting period.
Changes to the current physician and hospital reimbursement for fistula placement
    Physician payments: if both a hemodialysis catheter and fistula are placed on the same day, current Medicare payment policy results in only partial payment, reimbursing fully for only one of the two accesses placed on that day. We recommend that CMS provide a full rate of payment to the surgeon, interventionalist, and hospital for both accesses placed on the same day, when one of the procedures is creation of a fistula. This incentive will discourage delays in permanent access placement (fistula) among hemodialysis patients, by avoiding scheduling of the fistula placement to a date later than that of catheter placement.
    Physician payment: for incident hemodialysis patients, we recommend an additional incentive payment to surgeons, interventionalists, and nephrologists for any fistula that is used satisfactorily for hemodialysis at initiation and for the following four months, as indicated by sustained catheter removal.
    Facility payment: for patients who initiate hemodialysis urgently in the hospital, we recommend an expanded diagnosis-related group reimbursement to allow for prolonging the hospitalization to accommodate surgery for placement of a hemodialysis fistula or graft.