By Bill Peckham
I liked a lot Dori Schatell's remarks during the CMS Town Hall meeting on the ESRD Prospective Payment System Proposed Rule. Schatell is the Executive Director of the Medical Education Institute, which is probably best known for its troika of dialyzor centered websites: Home Dialysis Central, Kidney School and Life Options. Less know is the role Schatell has played online with MEI's discussion boards and also with the Dialysis_Support listserv where she has patiently answered questions for 13 years. Schatell is a tireless advocate for optimal dialysis through dialyzor education and involvement in their own care.
The dialyzor is central to MEI's evaluation of CMS policy. MEI has published a draft of their written comments to CMS on the proposed rule (PDF link). They are very good, very thorough. When given the opportunity to speak at the town hall rather than present a summary of these written comments MEI took the opportunity to address the entire renal community about a topic dear to my advocacy heart. As a strategy that was a great idea.
Here are the Medical Education Institute's comments Schatell presented to the CMS Town Hall Meeting 10/23/09:Thank you for the opportunity to speak, and for all of the countless hours you must have put in compiling this proposed bundled. I’m sure it wasn’t fun. Like many others today, we agree with the concerns that have been expressed about including oral medications and lab tests, the overall complexity of the bundle, and the impact of both on patient co-pays. But that’s not where I’ll be addressing my remarks today.
At the Medical Education Institute, we don’t work day-in and day-out in dialysis centers. So, that gives us the luxury to step back and observe the renal community from a bit of a distance. We take a long-term, strategic view. And one observation that we’ve made is that it’s very important to periodically challenge our assumptions. They are not gospel.
For example, the case-mix adjustment is based on completely unvalidated 2728 data—which means we are building a structure that can affect patient care on top of a house of cards. We strongly recommend that those data be validated—that a sample of them each year be checked for accuracy. Maybe you’ll find that they’re 100% accurate. But I don’t think so.
We also need to challenge the assumption that it’s okay to do dialysis just three times per week. We were very pleased to see that CMS included the possibility of more frequent hemodialysis treatments in the proposed bundle, with medical justification—but I think you need to go one step further, and eliminate medical justification. Here’s why. Each year in the U.S., about 110,000 people start dialysis—and about 87,000 people die, a rate that has only improved by about 2% over the past decade, and which is worse than any other industrialized nation.
Now, you might think that all of those deaths are evenly distributed among the seven days of the week. And, for peritoneal dialysis, they are. But for standard hemodialysis, that’s not true: Bleyer’s studies, compiled from USRDS data, found that the risk of death, of sudden cardiac death, is 50% higher than expected on the day after the 2-day dialysis weekend. And, in fact, it’s three times higher—triple—in the 12 hours before the next treatment after that 2-day gap. In a keynote address at the Annual Dialysis Conference last February, Dr. Carl Kjellstrand, a nephrologist from the Netherlands, estimated that more than 10,000 dialysis deaths per year in the U.S.—10,500—could be attributed solely to what he calls the 2-day “killer gap.”
Kathe LeBeau said, “If we get this wrong, patients pay with their lives.” I would argue that they already have.
We don’t close ICU’s on Sundays. We don’t give insulin to diabetics just three days per week. We don’t use heart-lung machines three times per week. It makes no physiological sense to replace a continuous body function with an intermittent therapy. If any practice in U.S. nephrology requires medical justification, it should be short, three times per week dialysis treatments!
Perhaps you noticed that all of the patients who spoke today were getting home dialysis, or had a transplant. At the Medical Education Institute, our mission is to help people with chronic disease learn to manage and improve their lives, and our goal is to create expert patients who can self-manage at a high level. The best way to do that is to have more home dialysis. So, it is vital to not threaten more frequent dialysis by rewarding clinics that don’t train and punishing the minority who do.You have an opportunity to improve dialysis patient care. I hope you’ll take it.
To adapt a phrase from London's subway - Mend the Gap.
The 2 day "killer gap" underlies the entire proposed rule - the payment is based on 13 payments a month, so it was an apt topic to bring up but more important than bringing these points to Medicare's attention was bringing these points to the renal community's attention. I'm not sure CMS's reimbursement is the barrier to every other day dialysis, so much as it is dialysis providers that have shown no appetite to challenge the status quo. (note that this is a world wide phenomenon. Every other day incenter dialysis is not offered anywhere in Europe or Oz either, AFAIK).
The Town Hall was a unique opportunity to talk to the whole renal community - Schatell made the most of it. Mend the Gap.
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