By Bill Peckham
When CMS published the proposed new dialysis payment model they did not use race or ethnicity as a payment adjuster but they did request comments on the idea (page 46 of large PDF):
We specifically invite public comment on the data issues presented in this section, other data sources for race and ethnicity we should consider, and specifically, the need for adjustments for race and ethnicity in the final ESRD PPS.
I think CMS was right to not include race as an adjuster.
Race is not a biologic concept, it is a social concept. And as a social concept it has been judged by the Supreme Court to deserve condemnation:
Over the years, this Court has consistently repudiated "[d]istinctions between citizens solely because of their ancestry" as being "odious to a free people whose institutions are founded upon the doctrine of equality." Hirabayashi v. United States, 320 U.S. 81, 100 (1943)
To contravene the doctrine of equality and include a case mix adjustment for race there would have to be a biologic basis for the various racial classifications. There is no biological basis for racial categories. A person's classification is commonly based on self-reported information. Self reported information is problematic, particularly with regard to racial/ethnic classifications.
Who is considered Hispanic? Who is Hispanic is a social, or mental construct that varies from community to community, however, checking that box would have serious consequences if you need dialysis. Under the two data sources CMS evaluated, REMIS/CMS Form 2728 and the Medicare Enrollment Database, those self identified as Hispanic would be reimbursed less, 14.2% and 16.3% respectively, then some who self identifies as white. It would be wrong to reimburse someone's dialysis less based on their identifying with a particular community.
The Kidney Care Council, DaVita and the American Kidney Fund (AKF) spoke in favor of including a race/ethnicity adjuster to the new expanded dialysis payment rate during their comments at CMS's Town Hall meeting Friday (Uremic Frost has posted the AKF's remarks). The AKF noted studies that report African Americans require higher doses of EPO to maintain a their hemoglobin in the target range. Their phrasing points up the problem. How are they using the term African American - what is their definition? Does it include those from the Caribbean? First generation immigrants from Africa? From South Asia?
Medicare was right to not include race/ethnicity adjusters in the proposed dialysis payment model. In general I believe, in the name of simplifying the payment model, that there should be fewer patient level case mix adjusters and that those that are used should be based on underlying clinical conditions.
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