Effect of cuts in reimbursement on first-year mortality in incident esrd dialysis patients: A nationwide population-based study over the period 1999 to 2007

[[abstract]]Introduction and Aims: Outpatient dialysis global budget payment (ODGB) under Taiwanese National Health Insurance was implemented in 2003 in order to cap the growing expenditure. The unit price was decreased from 1 NT dollar per point in 2003 to NT .94 per point in 2007. This may be as results of increasing market competition. The purpose of this study is to examine the association between the cuts of dialysis global budget payment, market competition and first-Year mortality in incident ESRD Dialysis Patients. Methods: This study used retrospective longitudinal data to examine the study question. The unit of analysis is at patient level. Study patients were incident end-stage renal disease (ESRD) patients (including HD and PD patients) between Jan 1st, 1999 and Dec 31st, 2007. Data source was from the NHI population-based claim data. The dependent variable was incident ESRD patient first-year mortality. Market competition was measured by using Herfindahl-Hirschman Index (HHI). HHI was calculated based on predicated patient volume given the concern of endogenous issue. Quarterly mean monetary value per 100 points under outpatient dialysis global budgeting was used to measure cuts in reimbursement. In addition, we also include interaction terms between point value and market competition. Multi-level logistic regression model was used as the primary statistical analytical tool. Results: During 1999 to 2007, number of dialysis facilities increased from 364 to 529 (45.33%) and the mean value of predicted HHI at zipcode level decreased about 7.08%, indicating markets became less concentration and more competitive. We then categorized markets into high, moderate and low competitive markets. Our results indicated that large reimbursement cuts were associated with higher mortality, in particular in a high competitive market. Specifically, for every NT$1 decrease per 100 points, which corresponded to every 1% reduction in average dialysis facility revenue, the odds of first-year mortality rate were 98% higher in high competitive market. On the contrary, in low competitive market, the odds of mortality were about 3.1% higher. Conclusions: The first-year mortality of ESRD patients increased under increased financial constrain from cuts in reimbursement. In addition, the findings indicated dialysis facilities in a high competitive market confronted with more financial pressure as a result of payment reductions may reduce their quality of care because they have fewer resources compared to those in low competitive market. Policy makers and stakeholders often concern whether the global budgeting payment policy affect the patient quality in a positive or negative way, especially when dialysis markets became more competitive. It is important to continuously monitor ESRD patients' quality of care as cuts in reimbursement under global budget system are implemented