Now that HR6331 (along with its ESRD provisions) is the law of the land, what's left for a dialyzor to worry about?

Now that HR6331 - the 2008 Medicare bill - has become law, what changes will people on dialysis see? We wont see many changes right away. The big change that will impact care is the enlargement of the Medicare reimbursement bundle, the expanded composite rate. When exactly the new payment scheme will go into effect is up to each provider - they can choose to take the expanded composite rate on January 1, 2011 or they can choose to have it phase in between January 2011 and January 1, 2014.  Either way on January 1, 2014 all Medicare dialysis reimbursement will be by the expanded composite rate.

Big Bundle, Big Questions

This reimbursement change is sure to impact day to day care in the unit but the change is also going to impact the ability of people on dialysis to travel. To what degree HR6331 impacts travel while on incenter dialysis depends on the answer to a fundamental question: what period of time does each expanded composite payment cover? HR6331 leaves this decision up to the Secretary of the  Department of Health and Human Services (DHHS). Currently the composite payment is made per treatment, routinely 13 times a month but HR6331 suggests other periods should be considered, from Section 153 (b)(1)(C):

The system under this paragraph may provide for payment on the basis of services furnished during a week or month or such other appropriate unit of payment as the Secretary specifies.

Expanding the composite payment already complicates travel while on incenter dialysis; if the expanded composite payment were meant to cover a week or a month of dialysis it could make travel while on incenter dialysis prohibitively complicated.

When You're Not Here, We Don't Get Paid

Expanding the bundle already complicates travel because some portion of the expanded composite payment is meant to reimburse for services provided once a month or once a quarter. HR6331 mandates the inclusion in the expanded composite payment, payment for previously separately billable medications (like iron), and previously separately billable lab services (like PTH testing).

If the Secretary of DHHS keeps the composite payment unit "per treatment" there is the question of what will happen when a patient travels. If someone leaves their home unit and dialyzes elsewhere for a week the three payments the host unit receives will include a portion of reimbursement meant to go to the monthly lab fees. Lab fees that will have to be paid by the home unit when the dialyzor returns. This has always been the case but now the problem will be exacerbated because the expanded composite payment will include a fraction of reimbursement for all periodically provided previously separately billable services. These fractions taken together will add up to a significant amount of reimbursement.

If the unit of payment is anything other than one treatment (e.g. one payment per week, one payment per month) it isn't at all clear how people will be able to travel for any length of time other than multiples of the pay period. If payment is per week, travel will have to match the pay period, one week. Unless the payment system is carefully structured to be travel neutral it is sure to have a dampening effect on travel. And while providers cherry picking dialyzors with low ESA needs will be monitored, generally it will be much harder to monitor the activities of providers when they are dealing with visitor dialysis requests. Will people with relatively high ESA needs find it harder to travel?

Travel Matters

The next Secretary of the DHHS will have to accommodate dialysis travel in Medicare dialysis reimbursement design or the reimbursement system will make travel while on incenter dialysis even more difficult. Many of these same questions will arise from hospitalizations. In general if someone is only in the unit long enough to have labs drawn and iron given the unit will not be fairly reimbursed. It would be possible to have formulas to make this work but it has to be seen as a problem for anyone to come up with a solution. We need to make sure the expanded composite rate does not make travel while on incenter hemodialysis any harder than it already is.

HR6331 has the potential to improve the provision of dialysis in the US but only if careful attention is paid to the details during implementation of the new reimbursement system. Accommodating travel is something that could easily slip off the table when the details of the new reimbursement system are decided upon. Travel is not a frivolous luxury, it is an important part of most healthy lives. For a reimbursement system to support good health, it must support good travel.

Comments

[Dennis Cotter]

Will people with relatively high ESA needs find it harder to travel? You raise an important question. High ESA needs might be a proxy for other complications or comorbidities and, as such, might indicate less of a need/desire for voluntary travel but more of need for travel related to health care treatment requirements. Understanding the underlying causes for high ESA needs is a current research topic at MTPPI (www.mtppi.org).

[Brady Augustine]

Bill, as we've seen with the new Conditions and with 6331, the intent is to be more centered on the patient. We discussed patient travel at the advisory board and rather than get into complexities, I expect CMS would just pay a per diem when someone is not with a facility the entire month. The new CROWNWeb system will allow the away facility to view and continue the patient's prescripion. We should be focusing on the good things in this Bill that are REAL rather than things that may or may not come to fruition. ~BAA

[Roberta Mikles]

Traveling is a contributing factor in supporting quality of life for many - visiting family, for example. I hope the industry, and all organizations, advocacy groups, etc., support the ability to travel when desired.

Brady, I wish the intent included more serious direction towards oversight and enforcement. We can have new Conditions focused on the patient (and clinical performance measures), but a well-conducted survey, with trained surveyors, often identifies quality care and patient safety areas that go unnoticed by facility staff. These identified areas often place patients in situations of potential or actual negative outcomes. I have noted this in surveys from many states. Roberta Mikles, RN Patient Advocate RMiklesRN@aol.com

[Bill Peckham]

Brady thank you for your work on the Advisory Board on the Demonstration of a Bundled Case-Mix Adjusted Payment System for End Stage Renal Disease (ESRD) Services. For those that are interested documents relating to the advisory board's work are available on the CMS web site.

Reading the transcripts of the meetings it is clear that your group identified numerous technical considerations/choices in regard to the design of an expanded dialysis composite rate. Each combination of elements - pay period and bundle composition - had its own sets of pros and cons. Now I've written a lot of words disputing the approach of controlling EPO use through the expanded bundle approach but I thought having a demonstration of the expanded bundle or even several flavors of an expanded bundle made a lot of sense.

A demonstration would have provided some good data to inform the choices that will go into the design of the new payment scheme. However, it was decided that there was no need for a demonstration for the bundle to go forward. That decision does not appear to be based on the advice of the Board.

Reading the legislation many of the choices the Board were weighing are now left to the next Secretary of DHHS but what data is there for he or she to use to make these choices? HR6331 Section 153 (b)(3)(C)ends the Committee's authorization, so as of July 15th there is no longer an Advisory Board.

I applaud the education and prevention programs included in the bill and certainly it was about time for there to be a routine way to adjust payments for inflation. However, the job is only half done. Without careful implementation the new payment scheme will not achieve all of its potential to induce optimal care.

Frankly the rule making process at CMS/DHHS has not been very transparent. How was it decided that there was no need for a demonstration? Indeed since your duties changed Brady there has been no "go to" person at CMS for ESRD issues. At the 2006 KDEC conference in Baltimore CMS chose to not participate.

HR 6331 is potentially better than no bill but only if in the details of the design it allows greater flexibility in the provision of dialysis (I'll be able to get iron at home) and does not accelerate dialysis industry consolidation. Done correctly the ESRD provisions in HR6331 will create a strong foundation to build on but even if HR6331 is perfectly implemented there will still be much to do, much to advocate for - I look forward to discussing access to higher doses of dialysis with CMS - I hope you're not buying into the QALY analysis. And it sounds like Roberta will be advocating for stronger adherence to the CfCs.

I'm afraid rather than focusing on the good things in HR6331 I'll continue to focus on how to improve the provision of dialysis.

Cheers,
Bill

[Brady Augustine]

Bill, hopefully as usual, we are both right. You and I have had some enlightening discussions over the years and patients should never shy away from organizing and advocating. Ultimately, CMS serves patients and the public.

Many talented and committed persons at CMS put in long hours to firm up the foundation of the Program and make it more effective, accountable, and patient-centered. The idea was that those providers who strive and succeed should be those who provide the best care - not the ones who provide the most separately billables (as CMS' own payment system encouraged). Yes, this is easily said but in this case, CMS has put some proof in the pudding to date.

The feeling was that by paying an expanded bundle, CMS would encourage efficiency but it also created a responsibility on CMS' part to measure and ensure facilities did not skimp now that the incentives ran the opposite direction. That is why CMS' CROWNWeb system is so important (see the Conditions for Coverage for more detailed explanation) because it will create a patient registry that will track Epo/Hgb (as well as other performance measures) for all dialysis patients using clinical rather than payment data. The system will produce comparative reports every quarter that will be available within 2-4 weeks of the end of the period. The expectation is that CMS, ESRD Networks, and state survey agencies will audit and view these data regularly and be able to respond more quickly and effectively to support quality improvement and patient safety. This system, if they implement it as designed, will be far and above what exists for any other clinical setting. And hopefully, CMS will at some time in the future, open CROWNWeb so that patients can see their data as well.

But these things will only help the existing system work better but the REAL solution is with innovation and new technologies that make the current system obsolete.

So, there are many good things going on at CMS re: kidney disease and only effective organization, communication, and advocacy (like this blog) will help us realize the potential of these activities (CMS has flubbed things before and Federal commitment tends to come and go). ~BAA

[Bill Peckham]

The proof of the pudding is in the eating which in this case means that we'll know if the new reimbursement scheme rewards providers with the best care long after the new reimbursement rules have taken effect.

If the success of the reimbursement change relies on the success of CROWNWeb that is worrying. I'm not a CROWNWeb expert but I am around those who are and I have heard their concern and frustration. On paper it sounds great but I'm sure we agree that some skepticism is in order. Implementing a ginormous IT change at the same time as huge new reimbursement changes come on line is scary terrifying worrying.

It could work. I hope it works. I know that you folks at CMS want it to work. However, you can't put the toothpaste back in the tube. If these changes accelerate industry consolidation it can not be undone a couple years later. I understand that the goal is to reward the corporations that provide the best care but it isn't clear if from the payer's perspective "best care" is the best clinical care or the most financially efficient care.

I hope this blog is an effective communication, and advocacy tool. I read Secretary Levitt's blog, I may not agree with his conclusions (on HR6331 for instance) and/or I may wish for blunter talk (on H5N1 for instance) but I am encouraged that he is blogging. I am encouraged by your willingness to comment here Brady. CMS has a very central role in all of this; to the extent possible I hope their commitment keeps coming and coming.

In the announcement of the new Kidney Research Institute in Seattle it was pointed out that more than 27% of Medicare's budget is spent on beneficiaries who have some degree of kidney disease. CMS has a big job ahead. Good luck, let us dialyzors know what we can do to help.

[Brady Augustine]

I am commenting only as John Q. Citizen. I am a big advocate for the front-line people at the ESRD NEtworks and at CMS because I know how they care. How their input translates to the bottom line depends on how policy interacts with the political process and many career-serving managers having little experience with kidney disease (or health care, for that matter).

I share your concern about CROWNWeb. Although most of the complaints are reactionary - this is a significant change, some are real and CMS needs to invest the resources and commitment necessary to make sure CROWNWeb works right out of the chute rather than compromising product quality to meet arbitrary deadlines. The business requirements for CROWNWeb have been led by ESRD Network 7 (http://www.fmqai.com/ESRD/CROWNWeb/) and they have done an admirable job. That said, a lot of other players have to act in unison to succesfully implement CROWNWeb and that, my friend, is not the government's strong suit.

USRDS has done some significant work with CKD and yes, the estimates are that care for persons with CKD accounts for 21% of Medicare's expenditures (see page 30 at http://www.usrds.org/2007/pdf/00a_precis_07.pdf).

On a more personal note, I no longer work in the kidney disease arena and currently serve the great state of Florida but it doesn't stop me from advocating for a community that deserves so much better than the system that currently exists. ~BAA

[Roberta Mikles RN Patient Advocate]

Brady, THANK YOU for your continued efforts.
Roberta Mikles RN Health Care Patient Advocate RMiklesRN@aol.com