CHAPTER 5 Disease management of the RRT Programme
5.2.2 Features of the RRT programme
5.2 Renal replacement therapy of the UCS
5.2.1 Background of the RRT programme
RRT was initially excluded from the benefit package when the UCS was launched in 2001 due to fiscal constraints and an unprepared system.
Gradually, the National Health Security Office (NHSO) responsible for UCS was pressured to expand benefits to include RRT by civil society organisations and patient groups (Tangcharoensathien, Kasemsap et al. 2005). Their justifications for inclusion were that it would save lives and prevent indebtedness and health impoverishment among UCS members.
Before launching the RRT programme, the NHSO commissioned a group of researchers to conduct a set of comprehensive studies relating to RRT
situations and the possibilities of an RRT programme for UCS beneficiaries. The intention was to present viable policy options to the NHSO board. Their final decision, supported by the government and the cabinet, was that the RRT would be provided universally regardless of age and socio‐economic status
(Dhanakijcharoen, Sirivongs et al. 2011).
Despite being cost‐ineffective, in 2008 RRT was adopted into the benefit package of UCS. The new health benefit covered RRT services for every UCS member. The justification was to help patients have access to the essential treatment and protect them from catastrophic spending due to health care costs (Kasemsap, Teerawatananon et al. 2006).
5.2.2 Features of the RRT programme
5.2.2.1 The PD-first policy
The UCS‐funded RRT has the ‘PD first’ characteristic. That means all new end‐
stage renal disease (ESRD) patients without contraindication to peritoneal dialysis (PD) must use continuous ambulatory peritoneal dialysis (CAPD) as the first‐line therapy, otherwise they need to shoulder the costs of the other
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modality of dialysis (hemodialysis) themselves9. HD patients who were on HD before the ‘PD first’ policy10, and patients with contraindications to CAPD, are eligible for full reimbursement of the cost of HD. Under the PD‐first policy, renal transplant and all essential high‐cost medications are also included in the benefits (Kasemsap, Chungsaman et al. 2009).
Before launching the RRT benefits, HD use was almost everywhere (352 HD centres across the country in comparison with 59 PD centres), but the
underlying reasons for the PD first policy were 1) CAPD requires fewer health professionals, and there were not enough nephrologists and trained nurses to provide universal access to HD; 2) CAPD is based on self‐management which means patients in rural areas do not need to come frequently for dialysis in town; and 3) CAPD showed evidence of cost‐effectiveness over HD in some countries, plus CAPD costs might be lower under the condition that the cost of the dialysis solution is cheaper (Kasemsap, Chungsaman et al. 2009). In contrast to PD’s advantages, patients who are on PD face a risk of infection, called
peritonitis, due to unclean environment or contaminated devices.
5.2.2.2 Separate payment mechanism and administrative function In the Thai UCS, costs of RRT are reimbursed according to the three modalities:
PD, HD, and KT. While staff salary is a part of the capitation payment of out‐
patient services, the RRT budget is administered separately and costs are reimbursed on a fee schedule basis.
The NHSO introduced bundled payments that combined multiple services into a single payment for each modality. Recently, it stopped paying for individual activities such as launching a PD centre, PD catheter (Tenckhoff catheter) insertion, home visit, and volunteer programmes that were originally meant to persuade providers to expand the service provision of PD. Reimbursements of PD and HD cover most activities associated with dialysis including counselling, catheter implantation in PD or vascular access in HD, consumables such as
9In this case, the NHSO supports the cost for EPO to prevent anemia in patients receiving HD.
10These patients had to pay copayment approximately £11 per session, but this rule was abolished in 2012.
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medical supplies and PD solution, and follow‐up. Erythropoietin and PD solutions are centrally purchased and allocated when they are requested from dialysis units. Reimbursements for kidney transplants cover all costs related to kidney operations of the patient and the donor, follow‐up process, and
immunosuppressant drugs (NHSO 2013).
In addition to the separate payment system, supply constraints, including
limited numbers of CAPD nurses, nephrologists, CAPD centres, and limited fiscal capacity, challenged the implementation of the RRT programme. Policy makers of the UCS decided to manage the programme separately from the mainstream by splitting the RRT budget and setting up an ESRD administrative unit within the central NHSO. The intention of this split was to provide a managerial function for the RRT system (Tantivess, Werayingyong et al. 2013).
5.2.2.3 Co-ordinated system of RRT programme
The UCS’s RRT programme is a system of coordination between various sectors:
the NHSO, the Government Pharmaceutical Organization, the Central Office for Healthcare Information, the Renal Registry under the Thai Red Cross, the professional body of the Thai Nephrology Society, public and private RRT providers, primary care units, and patients and their communities.
The local RRT centres are mandated to register patients diagnosed with renal failure or patients who need RRT. A patient needs to be approved by the regional NHSO before starting RRT at an RRT centre. Once an RRT service is given to a patient, the RRT centre sends information about activities and PD solutions or erythropoietin (EPO) use to the central NHSO in order to be reimbursed the dialysis and staff fees according to the agreed guideline
protocol. The Central Office for Healthcare Information is responsible for claims from HD patients. Medications, namely EPO and PD solutions, are reimbursed in the Vendor Managed Inventory System by the Government Pharmaceutical Organisation. The Government Pharmaceutical Organization is in charge of delivering EPO/dialysate to RRT centres, as well as delivering dialysate to CAPD
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patients’ houses. The renal registry acts as a middleman to collect ESRD prevalence and incidence data (NHSO 2013), Figure 5‐1.
Figure 5‐1 Coordinated system of RRT management
RRT=renal replacement therapy, CAPD=continuous ambulatory peritoneal dialysis, HD=hemodialysis, GPO=Government Pharmaceutical Organization, CHI=Central office for Health care Information Source: NHSO (2013), ESRD administrative unit (2011)
Figure 5‐2 shows a patient journey along the NHSO’s RRT protocol. In the usual care system, if the patient has diabetes or hypertension, chronic kidney disease may be detected by the screening programme when the patient meets a GP in a primary care unit or an internist in the outpatient department of a larger health facility. When the patient presents with decreased kidney function, they will be referred and looked after by professionals in the RRT unit to. A nephrologist confirms the ESRD diagnosis when the patient’s GFR level reaches 15
mL/min/1.73 m2. If the patient presents no signs or symptoms of kidney failure, they will be provided with information on the treatment options when their GFR level drops to 6 mL/min/1.73 m2. If the patient agrees to start dialysis, they will be registered with the RRT programme, or alternatively they will be living with conservative therapy (without dialysis).
The RRT programme uses PD as the first treatment modality. A patient without contraindications to PD will be trained for self‐care management. During the training process (approximately 3 months), nephrologists and PD nurses
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provide dialysis care, a pre‐PD programme, to the patient. This includes laboratory tests, educational sessions for the patient and carer, and catheter insertion. Once the patient has completed the assessment for commencing PD, the regional NHSO committee has the next role to approve the patient for entering the RRT programme. The committee also has a role in approving initiating dialysis on HD or switching to HD if the patient is contraindicated to PD or fails using PD. The patient can register for a kidney transplant and have an operation once they are accepted as a transplant candidate (NHSO 2013).
Once the patient has established PD, they will be followed up by the
nephrologist and other PD staff for evidence of complications and peritonitis, and routine medication every 1‐2 months. The patient is also referred to their local primary care unit and is offered occasional home visits. A family member is encouraged to come along with the patient during the training period in order to be able to support the patient with PD exchanges at home.
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Figure 5‐2 A patient journey in the RRT programme
CKD=chronic kidney disease, CAPD or PD=continuous ambulatory peritoneal dialysis, HD=hemodialysis, KT=kidney transplant, RRT=renal replacement therapy