By Bill Peckham
In July I
wrote, worrying about the effect on travel of expanding
Medicare's dialysis payment composite rate. In that post I really
only considered the impact of an expanded bundle that kept the
payment frequency the same, 13 times a month/per treatment. I hadn't
seriously consider the possibility of paying for dialysis on a basis
other than per treatment, that's not the case for everyone. In the
corridors of DC and the meeting rooms of Baltimore a monthly
composite rate is being seriously considered. Based on phone calls
I've participated in and conversations I've had, a monthly
reimbursement rate is being discussed at the GAO and CMS. What's
driving this? The driver is the text of the legislation.
HR
6331 leaves the payment frequency up to the Secretary of the
Department of Health and Human Services but while doing that the
relevant text of the Bill suggest that keeping the current per
treatment payment frequency would not be Congress's first choice:
SEC. 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.
By mentioning two payment periods specifically - per week and per month - Congress is setting the agenda in discussions throughout the administration. It is the job of the GAO, CMS, et al to report on what the legislation requires and what has to be done to implement the law. What is discussed in their reports, the topics up for discussion, is determined by the legislative language.
The legislation says services furnished during a week or month so the reports will discuss the weekly or monthly payment periods. The legislation also does say or such other appropriate unit of payment which would allow consideration of anything from the current per treatment payment model to a yearly onetime lump sum payment but the emphasis is on longer pay periods. That emphasis, I fear, will be reflected in how agency analysts spend their time and ultimately reflected (if not amplified) in the reports.
Monthly and weekly payment periods ... compared to a per treatment pay period they are similar in their problems, for simplicity sake I'll say monthly. A monthly payment would mean that for a given month each patient would have a "designated dialysis provider" (not a "designated dialysis unit". A large dialysis organization, with a geographically wide network of units and widespread acute services would have options not available to smaller dialysis organizations. I am taking the view from a small dialysis provider perspective, the large dialysis provider perspective would be somewhat different), should the patient receive dialysis from a different provider during the month there would have to be a payment from the designated provider to the non-designated provider. I can't work out how hospitalizations would be handled - the payment rate is not the same for inpatient and outpatient dialysis; it's Part A vs. Part B - but travel would be made more difficult. Expanding the bundle already makes travel harder, changing the payment period from per treatment will create additional barriers. Patient travel would require direct transfers of funds between providers or require patients to pay and then get reimbursed.
It boggles the mind. I suppose foreign travel would be a windfall for the designated provider but would that also be true if a patient were to skip a treatment? If in the course of travel a patient took two weekends in a row (not an uncommon strategy) would the designated provder benefit from the lower dose of delivered dialysis? How worried are the reporting agencies that expanding the payment period will manifest an incentive to decrease dialysis frequency? I would be very worried about that.
I hope that the the reporting agencies give travel its due. There is already a bias against dialysis patient travel in Medicaid's dialysis reimbursement. We should not erect barriers to dialysis patient travel with Medicare reimbursement. Travel is not a frill, it is an important part of a healthy life. It is important that the reporting agencies give the per treatment payment option as much study and analysis time as the two pay periods mentioned in the legislation and it is important that the reporting agencies recognize travel as an important part of life. Travel on dialysis is hard enough, reimbursement should not make dialysis patient travel harder.
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