GAO reports CMS plans to end medical exception payments under expanded bundle

By Bill Peckham

RenalWEB links to a 32 page GAO report (pdf link) that looks at the impact of expanding the Medicare payment bundle (due to happen in 2011) on the provision of home dialysis. The GAO paid particular interest to the costs of providing more frequent home hemodialysis. The headline is that CMS Should Monitor Effect of Bundled Payment on Home Dialysis Utilization Rates.

That's a good idea but the real news is on page 16 and 17 of the report (pages 20 and 21 of the pdf):

Indeed, under the current partially bundled payment system, we found that some home dialysis providers now have been granted medical necessity exceptions to receive Medicare reimbursements for additional dialysis treatments beyond three per week. CMS officials told us that they are unlikely to allow these additional reimbursements under the expanded bundled payment system.

That is bad news for the future of frequent home hemodialysis.

Comments

[Peter Laird, MD]

This issue will continue to come back time and again to the lack of a large randomized, controlled trial "proving" the effectiveness of quotidian dialysis no matter how many well done observational studies show such a benefit. America will go down this path stubornly refusing to acknowledge what all other western nations readily acknowledge. CMS continues to request and demand this evidence before they will even consider payment for more than the standard treatment options.

What an irony in the fact that before CMS became responsible for American dialysis patients, the standard of care was 8 hour sessions, 3 times/week. Thus the self imposed standard of care has been and will continue to be based on government mandated standards and not on evidence based medicine. I have no kind words for the continued substandard American standards that CMS will continue to propagate. I fear the government mandated standards that will soon be imposed on all Americans if the renal program serves as the example of what is to come for all. Just MHO.

[Rich Berkowitz]

Ouch! When I talked to Barry Straube a couple of weeks ago, I stressed how much was being saved on the Part A side, and if only CMS would apply those savings to Part B treatments thet is could be budget neutral. If they take treatments away from us, it would mean less healthy some dialyzors, ergo more hospitalizations.

I'm also wondering if we have any play with the fact the Social Security Law stated there should be incentives for home dialysis. If they take treatments away, even if it's for medical necessity, what are the incentives? Maybe we have a cause of action.

[Miriam Lippel Blum]

As a home dialyzor with significant cardiac issues, I do six physician prescribed treatments a week. To be able to minimize fluid and toxin accumulation has, no doubt, reduced stress on my heart and allowed me a quality of life worth living.

I doubt highly that the dialysis provider I use would allow me to continue to do six if the medical exception is removed and they are only reimbursed for three.

In my opinion, CMS would be engaging in cruel and unusual punishment, and actively contributing to my death by removing the exception.