Need for an incentive-based reimbursement policy toward quality care for dialysis patient management

Background. In view of the growing dialysis population and the increasing reimbursement cost in the industrialized countries, a critical evaluation of the dialysis economy is warranted. Methods. Data for the reimbursement and dialysis patients' statistics were collected from the National Medical Care Expenditure (NMCE), 1979-1996, which was published by the Japanese government, and the article "An overview of regular dialysis treatment in Japan," 1979-1998, by the Japanese Society for Dialysis Therapy, as well as unpublished data from the Yokohama Dai-ichi Hospital and 10 affiliated urban dialysis centers. Results. From 1979 to 1996, the dialysis population increased 5.2 times and the NMCE increased 2.5 times, whereas the endstage renal disease (ESRD) payment increased only 1.8 times. Because of a drastic reduction in the dialyzer cost and the dialysis-related technical fee, both the percentage of ESRD-related payment within NMCE and ESRD payment per capita per year decreased from 5.4 to 4.1% and from 16.3 million yen to 5.6 million yen, respectively. Despite this drastic cost reduction, the patient survival and quality of life determined by the social rehabilitation rate did not decline. Conclusion. The Japanese health insurance policy for dialysis management achieved a successful cost cut during the 1979-1996 period by using an incentive-based payment system toward quality care. However, the forthcoming further exponential increase in the dialysis population may put the dialysis economy and hence dialysis care quality in jeopardy. Effort must be made to reduce the ESRD-related cost through prevention of the progression of kidney diseases, propagation of renal transplantation, and internationalization of continuous ambulatory peritoneal dialysis and crythropoietin cost. A reduction in dialysis reimbursement, if necessary, must be achieved through an incentive-based system toward quality patient care.