Expanding the payment bundle - epo is center stage.

By Bill Peckham

Kieth over at the Renal Business Today's blog links to a very interesting discussion on the Health Affairs blog, Epoetin Payment: Focus On Clinical Benefit. The author Dennis Cotter is President of the Medical Technology and Practice Patterns Institute. He is concerned that the way the new expanded bundle is being structured builds in the over use of epo. I'd summarize the point as, since future reimbursement is based on past usage and epo was being over used in the past, pegging future reimbursement to this past inflated usage leads to inflated reimbursement.

Commenters have made good points which Cotter replies to in his own post comments, offering substantive counter points. This exchange is continuing and holds a lot of promise.

Speaking as someone on the sharp end of the needle I think the greatest problem with CKD healthcare remains the high mortality rate among those with severe chronic kidney disease (CKD5) who use incenter dialysis; Cotter seems to be saying the problem is spending too much money on anemia medications.

I have doubts about Cotter's contention that doses could be reduced by 50% but I had not previously considered the implications of plateauing in hyporesponsive patients (referenced in Cotter's 12/3 comments). There is a question about how much money can be saved but my suggestion (comments 12/22) stand - whatever the savings the money should continue to support people with CKD. As far as concerns over overdosing and under dosing, the virtuous thing about CMS buying epo directly is that without the taint of profit we will have confidence that medical practice is based on medical knowledge rather than a grim financial calculus.

The other trouble with Cotter's analysis is that it does not value quality of life when deciding how important it is to control anemia. I think current quality of life measures are robust enough to use (for example the SF-36) but in any case I am confident that medical knowledge evolves, conventional wisdom evolves. Cotter's analysis does not consider the impact of untreated anemia on the patient's quality of life. Quality of life does exist and it varies with degrees of anemia. Medical knowledge (and payment practice) will, I think, evolve to recognize the value of QoL measures.

It's a good discussion. I hope it continues. My bottom line though is resources should be redirected, not cut. CMS is obliged to make good on Congress's 1972 promise.

Comments

[Nancy H. Spaeth, RN]

Bill,
As someone who lived a life before Epo, was in the clinical trials for it and lived life after Epo, I could not agree with you more!

I also must comment that those who get more dialysis get a better quality of life. I have done both over night home hemo and 4 hours 3 times a week, as well as CAPD. There is NO comparison. The 4 hours 3 times a week is awful and in no way can contribute to a good quality of life. How did they ever come up with that formula?
Nancy

Nancy H. Spaeth, RN

[Wallyz]

Nancy- they did the same calculus that Cotter is using now. 3X4 fit a particular business plan for cost and maintaining a minimum level of care, so there it is. QoL doesn't apply for kidney patients in most settings.