• Health Policy and Government Relations
• Contact Congress - Take Legislative Action
• SVS Health Policy Committee Meets with Senators/Staff
• Priority Issues
• Imaging Cuts
• SAAAVE Act
• Physician Payment
• Pay For Performance (P4P)
• Fistula First Initiative
• Malpractice Reform
• Reimbursement
• Regulatory Issues
• Political Action Committee
• 110th Congress Committee Assignments

SVS Taking a Leadership Role in CMS Fistula First Initiative 

In 2004, the Centers for Medicare and Medicaid Services (CMS) introduced the Fistula First Initiative for the purpose of significantly increasing the use of native arteriovenous fistulas (AVF) for hemodialysis access. The Initiative is engaging vascular surgeons, nephrologists, dialysis facilities, primary care physicians and patients in changing practices to assure that AVFs are the first choice for every eligible patient in order to improve the quality of care provided to Medicare beneficiaries suffering from end-stage renal disease.

The Fistula First Initiative’s goal is to more than double the percentage of patients with fistulas to 66% over the next five years. The current national average is 29% for incident patients and 31% for prevalent patients.

SVS is taking a leadership role in shaping the Fistula First Initiative. As requested by CMS, SVS endorsed the project and Robert Zwolak, MD provided initial information on behalf of SVS regarding the promotion of the use of AVFs. SVS commented that it foresees a major challenge in the data collection that will be necessary to document surgeons’ ability to not only create fistulas, but to create fistulas that mature to serve as functioning access conduits.

Michael Lilly, MD represented SVS at the initial Fistula First Breakthrough Initiative Stakeholders Meeting in November 2004. Following the meeting, Dr. Lilly recommended that SVS assemble a team to participate in the project and he also serves on the Quality Measures and Public Reporting and Professional Education and Training Sub-groups. In addition, Dr. Zwolak serves on the Delivery Systems and Operations Sub-group.

In February, SVS was asked to chair one of five subgroups, the Vascular Surgeons and Hospitals Group. An initial conference call was held with Clifford Sales, MD and Harry Schanzer, MD serving as co-chairs. Of particular interest was the discussion of creating incentives for positive outcomes – also known as pay for performance. With the emphasis on the Fistula First Initiative by CMS, it is possible that the first pay for performance surgical project will be hemodialysis access. 

The first meeting with stakeholders and subgroups was held in March with Dr. Sales delivering a presentation focused on the following issues: vascular laboratory reform, reimbursement, and education. Three more 2005 stakeholder meetings are scheduled for June, September and December.

The Initiative is building on prior work and taking advantage of system-level diagnosis and strategies for improvement. The following summarizes the key principles that govern the development of change strategies:

1. Address the fundamental failure points in the system that are operational enough to be adopted with manageable levels of external support.
2. Spread successful ideas on a End-Stage Renal Disease (ESRD) Network and national level.
3. Institute collaboration among ESRD Networks, providers and key health professionals.
4. Leverage resources, such as Network Quality Improvement resources and other relevant sources of expertise and support.
5. Minimize burden on dialysis facilities.

The initiative is also using change concepts as a general approach in developing specific ideas for changes that lead to improvement. For surgeons, the Institute for Healthcare Improvement (a non-profit organization which offers resources and services to help health care organizations make dramatic and long-lasting improvements), in conjunction with CMS, has developed the following change concepts as a starting point:

1. Use a full range of appropriate surgical approaches.
2. Place secondary AVFs in patients with AV grafts.
3. Place AVFs in patients with catheters where possible.
4. Establish procedures for monitoring and maintenance to ensure adequate access function.
5. Provide outcomes feedback to guide practice.

In addition, the following key elements of CMS’s Quality Improvement Program are supporting the Fistula First Initiative:

1. CMS Dialysis Facility Compare at www.medicare.gov - contains dialysis facility service and quality information on all Medicare approved dialysis facilities in the United States.
2. Revised ESRD Conditions of Coverage, which must be met by all dialysis facilities participating in Medicare.
3. ESRD Clinical Performance Measures’ project - collects data annually to identify and track opportunities for improvement in areas that include adequacy of hemodialysis and peritoneal dialysis, anemia management and vascular access management.

Additional information may be accessed at www.fistulafirst.org.