Table 4 effects of the prospective payment systems and value-based payment systems for dialysis services based on the studies

1

cost saving (efficiency improvement)

reducing unnecessary services

Use of ESAs reduced in patients who may not benefit from them (USA, 2011 PPS ^b) [10],

Reduce EPO dosage to the lower margin in guidelines (France, global budget) [64]^a

reducing services in the bundle

substituting expensive drugs with their less expensive alternatives (for example ESAs were substituted by iron products, less expensive vitamin D products were substituted by more expensive types) (USA, 2011 PPS) [12],

Encourage to use less expensive options to control anemia e.g. reduction in EPO dose and increase in patients receiving IV ^c iron) (Japan, bundled FFS) [27, 68],

The cost of antihypertensive drugs during the “dialysis visit” reduced (Taiwan, global budget) [23],

EPO use reduced (USA, 2011 PPS [11, 12, 28, 41, 46], (Italy, bundled FFS ^d) [65]^a, (Japan, bundled FFS) [27, 68]

IV iron use reduced (USA, 2011 PPS) [11]

IV vitamin D use reduced (USA, 2011 PPS) [26]

dialysis time shortened (Italy, bundled FFS) [65]^a,

The nursing staff employment reduced (Belgium, capitation)^a [17]

2

Shift in service cost

increasing services outside the bundle

“Non-dialysis visits” with the prescription of antihypertensive drugs increased (Taiwan, global budget) [23],

transfusion rate increased (USA, 2011 PPS) [11, 25, 28],

IV iron use increased (Japan, bundling) [27, 68],

iron products often therapeutic substitutes for ESA, increased (USA, 2011 PPS) [12]

3

quality of care

quality reduction through the cost reduction incentive

Hgb ^e level reduced (USA, 2011 PPS) [11, 28, 40, 41],

PTH level increased (USA, 2011 PPS) [28, 50],

physicians may reduce EPO use and their attempt to reach Hgb targets (Italy, bundled FFS) [65]^a,

Cause a short dialysis time (Italy, bundled FFS) [65]^a,

It constrains the quality of ESRD care (Spain, bundled FFS) [67]^a,

Low incentive for quality attentions may affect quality of care:

no incentive to improve quality by more sophisticated and more expensive techniques, like the use of biocompatible or high flux membranes, or the use of hemodiafiltration, or for the duration of the session (Belgium, capitation) [17]^a,

Use low-cost dialysis membrane (France, global budget) [64]^a

quality improvement through the quality indicators

fistula use increased (USA, 2011 PPS) [49],

short treatment times (less than 4 h) reduced, Kt/V improved, Hgb levels improved (Germany, quality assurance system) [39]

fistula use increased (Queensland, quality assurance system) [31]

4

risk of provider

adverse selection

cherry picking occurred “sometimes” or “frequently” (USA, 2011 PPS) [34]

Decreasing the profit

longer dialysis without additional reimbursement, may lead to higher costs (Belgium, capitation) [17]^a,

5

modality choice

change in use of peritoneal dialysis (PD) or home hemodialysis (HD)

PD use increased (USA, 2011 PPS) [12, 28, 33, 35,36,37, 48],

home dialysis use increased (USA, 2011 PPS) [44]

(PD use increased, Queensland incentive payments) [31],

HD increased (Germany, capitation) [69]^a,

the rate of PD is low, since it is less profitable (Italy, bundled fee) [65]^a