因應人口快速老化，醫療費用的快速增加，門診論量計酬為主的方式必須改變；支付制度的設計須要兼顧病人照護品質與醫療費用控制。隨著多重慢性病患的增加，引導整合式或周全式照護必須更被鼓勵；慢性透析病患常合併多重慢性病( 如高血壓、糖尿病及心血管疾病)，有較高發生中風、心肌梗塞、鬱血性心臟病、感染性疾病與敗血症之風險，有較高的門急診住診利用與死亡率。美國聯邦醫療保險和聯邦醫療補助計畫服務中心(Centers forMedicare & Medicaid Services，CMS) 推動慢性透析周全式照護模式(Comprehensive ESRDCare Model，CEC 模式)，落實腎臟科醫師整合性照護責任，包括個案管理、24 小時緊急諮詢專線、與合作醫院的轉診機制，以提升醫療照護品質，減少片段式照護和住院，期望慢性透析照護團隊提供慢性透析病患更積極的前端照顧保健服務；腎臟科醫師等於透析病人的家庭醫師，由腎臟科醫師負所有的前端照顧保健及疾病治療之責，腎臟科醫師專業無法處治的疾病，必須將透析病患轉介到其他專科醫師或醫院就診，以免因延誤就醫導致更嚴重的併發症；腎臟科醫師將周全式照護保健做的越好，讓病人更健康，門診及住院利用減少，節省的醫療費用，保險人可以回饋分給慢性透析照護團隊；若前端的照顧保健做得不好，讓病患醫療費用增加，會造成該腎臟科醫師及慢性透析照護團隊收入減少；期望創造病患、慢性透析照護組織及保險人三贏的局面。CEC 模式在第一年計劃結束時共節省了7,500 萬美金，第二年透析被保險人住院率下降20%，再住院率下降27%；雖然CEC 模式被肯定為一個值得推行的整合治療模式，可提升透析病人的醫療品質及降低醫療成本，仍需預防照護團隊可能誘導末期或慢性腎臟病人接受保守治療或居住於安養院(hospice) 以節省透析或住院之費用。以健保署過去在保險對象醫療利用資料分析的能力、及多年執行整合照護門診、疾病論質計酬、全民健康保險家庭醫師整合性照護制度試辦、論人計酬試辦等計畫的經驗，面對人口快速老化、多重慢性病老人的增加、及健保財務支出大於收入等情形下；要如何努力提供兼具醫療品質與控制醫療費用，宜思考實行慢性透析病患整合式照護試辦計畫的可行性，以降低慢性透析病患片段式照護和門急住診利用，讓病患獲得更好的健康品質，讓參與之透析機構獲利增加，並減緩健保署之透析支付總點值的上升。

The fee for service payment system of outpatients should be changed because of the rapid growing elderly population and medical expenditure. The purpose of payment system is to control the quality and expenditure of health care. As the increasing number of patients with multiple comorbility, intergrated or comprehensive care model should be encouraged. The high costs of chronic dialysis patients are often the result of underlying disease complications (stroke, myocardial infarction, congestive heart disease, infection or sepsis) and multiple co-morbidities (hypertension, diabetes and cardiovascular disease), which can lead to higher rates of out-patient and emergency service, hospital admission, readmissions, and mortality than the general population. Therefore, comprehensive end stage renal disease care (CEC) model was implemented in America by Centers for Medicare & Medicaid Services (CMS) to put dialysis clinics and nephrologists at the center of the patient’s care, with the goal to decrease costs and improve quality by reducing fragmented care and admission. The CEC model included case managers and coordinators, 24 hours emergency consultation, and transfer system. In CEC model, nephrologists work as primary physicians to provide patients centered care that will address patients’ health needs, both in and outside of the dialysis clinic. The organization of dialysis participating in CEC model may lose or gain financially depending on clinical outcomes and performance on quality metrics and on total health care costs incurred by their patients, with financial responsibility for costs of all care. In performance year 1 of the CEC model, results have been extremely promising. $75 million was saved, primarily in hospital spending and post-acute care. In performance year 2, hospital admissions and readmission had been reduced by up to 20% and 27%, respectively. Because of the ability and experience on health care data base analysis, integrated out-patient care program, fee for quality program, family physician integrated health care program, and pilot study of capitation payment system, National Health Insurance Administration may consider a pilot study of comprehensive care in chronic dialysis patients with the goal to decline the growth of dialysis expenditure and improve quality by reducing fragmented care, out-patient and emergency service, and admission. The participating dialysis organizations in the pilot study may get more profit from sharing save.