Is there Cherry Picking in the ESRD Program? Perceptions from a Dialysis Provider Survey

Background and objectives: Changes in ESRD reimbursement policy, including proposed bundled payment, have raised concern that dialysis facilities may use cherry picking practices to attract a healthier, better insured, or more adherent patient population. Design, setting, participants, & measurements: As part of a national survey to measure beliefs about drivers of quality in dialysis, respondents were asked about their perceptions of cherry picking, including the frequency and effect of various cherry picking strategies on dialysis outcomes. We surveyed a random sample of 250 nurse members of the American Nephrology Nurses Association, 250 nephrologist members of the American Medical Association, 50 key opinion leaders, and 2000 physician members of the Renal Physicians Association. We tested hypothesized predictors of perception, including provider group, region, age, experience, and the main practice facility features. Results: Three-quarters of respondents reported that cherry picking occurred sometimes or frequently. There were no differences in perceptions by provider or facility characteristics, insurance status, or health status. In multivariable regression, perceived cherry picking was 2.8- and 3.5-fold higher in the northeast and Midwest, respectively, versus the west. Among various cherry picking strategies, having a low threshold to 'fire' chronic no-shows/late arrivers, and having a low threshold to 'fire' for noncompliance with diet and meds had the largest perceived association with outcomes. Conclusions: Under current reimbursement practices, dialysis caregivers perceive that cherry picking is common and important. An improved understanding of cherry picking practices, if evident, may help to protect vulnerable patients if reimbursement practices were to change.