Coordination of care in disease management: Opportunities and financial issues

Patients with end-stage renal disease (ESRD) and pre-ESRD require higher ut ilization of health care resources. Current reimbursement modalities contri bute to the fragmentation of care, and inadequate financial information obs cures the fiscal impact disease management's coordination of care can have for this population. Ignoring the extreme costs of the first 3 months of he modialysis underestimates costs by as much as 16%. Potential areas of coord ination and the financial benefits are discussed. In each venue of the care settings of a patient with chronic renal failure (CRF) they may receive ex cellent service. Too often there is not optimal coordination of care betwee n these venues, and in fact the fragmentation of care can cause unnecessary wear and tear on the patient, and increases the overall expense to a healt h care system. Understanding sources of fragmentation, reimbursement effect s, and potential corrections will enhance the patient's voyage through the system. This article provides some examples of the discoordination that pre sently exists and financial implications especially during the transition o nto dialysis. In patients with end-stage renal disease (ESRD), each arena o f care has criteria established to quantitate quality. None of the settings , whether it is the dialysis unit,lie hospital, the skilled nursing facilit y, or the physician's office, exists in the absence of regulations. These m ay be state or federal, National Council on Quality Assurance (NCQA), Healt h Plan Employer Data and Information Set (HEDIS), water standards, Occupati onal Safety and Health Administration (OSHA), fire codes, physician peer re view, Medicare billing, Health Care Finance Administration (HCFA), the ESRD networks, credentialing, health maintenance organization (HMO) insurance r equirements, pharmacy benefits and formularies, safe harbors, "antikickback ," or National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF- DOQI) guidelines. For all the providers of care, the other critical compone nt is the ability to have adequate income to stay in business, and make a p rofit. Each becomes very astute at working within the confines of the regul atory restrictions to provide good care. However, the continuity of care ca nnot be the overwhelming issue for many of the providers. The only person t hat is involved in every arena is the patient. The only provider that curre ntly crosses over most arenas is the nephrologist. But the other element th at exists in each arena is a payer.