You may or may not have heard about some of the recent health care issues affecting the kidney community. In September, the Centers for Medicare and Medicaid (CMS) issued a proposed bundle affecting individuals who are on dialysis. The nearly 600 page document has been the topic of many deliberations. The American Association of Kidney Patients (AAKP) has been involved in many discussions and its Public Policy Committee has spent time reviewing the document to assess its affect on patient care.
As always, AAKP’s main concern is the impact this proposal may have on patients’ access to care as well as quality of care. Below is an overview of the changes, AAKP’s comments, links to resources to learn more and what you can do to have your voice heard.
BACKGROUND INFORMATION
Medicare payment to ESRD facilities (dialysis units) for outpatient maintenance dialysis services provided to Medicare beneficiaries with ESRD is currently based on a prospective payment system known as the case-mix adjusted composite payment system. The base composite rate covers the costs of the dialysis treatment and certain routine drugs, laboratory tests and supplies furnished at home or in a facility. Other items and services, particularly injectable drugs and non-routine laboratory tests are not included in the composite rate and are billed separately to Medicare. Separately billable services represent about 40 percent of total Medicare payments per dialysis treatment. The base composite rate is adjusted by a drug add-on payment to account for changes in the drug pricing methodology that occurred in 2005 and by case-mix factors, that is age, body size and special adjustment for pediatric patients. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires CMS to develop and implement by January 2011, a fully bundled prospective payment system (PPS) for dialysis services provided to Medicare beneficiaries who have end-stage renal disease (ESRD). This replaces the current basic case-mix adjusted composite payment system (described above) with a bundled ESRD prospective payment system, or the ESRD PPS. There will be a four-year transition period with full implementation beginning Jan. 1 2014.
MIPPA further requires CMS to create a quality improvement program (QIP) that would help ensure ESRD facilities provide high quality care to their patients. The QIP would have payment consequences beginning for services provided on or after Jan. 1, 2012.
AAKP supported Congress’ effort to shift its Medicare payment systems to increasingly focus on high-value care. But also expressed concerned that without thoughtful implementation and appropriate oversight, these changes may increase barriers to care for individuals with kidney disease.
In May 2009, AAKP sent correspondence outlining its concern that this new bundled payment could limit access to care for patients who might inadvertently decrease the bundled reimbursement. The Association explained how a patient who medically requires more previously unbundled drugs and/or diagnostic studies, and who is not accounted for in the case mix adjustment methodology, may not be accepted for treatment in facilities trying to maximize their margin. Any system that links financial incentives or financial disincentives with limiting access to health care for certain types of patients is easily abused by cherry picking and requires thorough confirmation of self reported performance measures. As decisions were being made, we urged Congress and CMS, especially during the implementation of ESRD-related MIPPA provisions, to initiate appropriate controls to ensure these issues are addressed and minimized to ensure equal patient access to high-quality care. This high-quality care includes biologicals and laboratory tests as well as modality options especially those resulting in improved quality of life and clinical outcomes.
AAKP’s COMMENTS
AAKP’s main focus for the past 40 years has been to ensure quality of care and access for all dialysis patients and potential dialysis patients. AAKP’s verbal comment at the Town Hall Meeting of Oct. 23 is posted on the AAKP Web site.
AAKP is also formalizing a written response, which is due by Nov. 16 (extended until Dec. 16). If you would like to share your comments with AAKP, please send an e-mail to policy@aakp.org.
RESOURCES
- Centers for Medicare & Medicaid Services held a Town Hall Meeting in Baltimore to hear from interested parties about the bundling proposal. The meeting took place from 9 a.m. to 12 p.m. ET Friday, Oct. 23, 2009. If you missed the call you can access an archived copy of the Town Hall meeting until the conclusion of the comment period, which is Dec. 16. To access the conference call, dial 1-800-642-1687, conference ID number 33239635.
- Press Release from CMS regarding new prospective payment system
- Medicare Bundling Proposal (large file 547 pages)
SHARE YOUR THOUGHTS WITH CMS
You are encouraged to share your thoughts and experiences with CMS. The deadline was orginally Nov. 16, 2009 - however it has been extended until Dec. 16, 2009). Here’s how to comment:
1. Online at www.regulations.gov. Follow the instructions under the "More Search Options" tab. Or, use this direct link: www.regulations.gov/search/Regs/home.html#submitComment?R=0900006480a30c15
2. By mail to arrive before Dec. 16 at:
Centers for Medicare & Medicaid Services
Dept. of Health and Human Services
Attention: CMS-1418-P, P.O. Box 8010
Baltimore, MD 21244-8010
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