By Peter Laird, MD
The case mix adjusters also have several key inpatient factors that will need to have close data recall and sharing between inpatient and point of outpatient care parties. This will increase the secretarial administrative duties with the dialysis unit and most likely will be accomplished by added employee positions.
In addition, the physician who wishes to stay in compliance will need to update their training on an annual basis since it is likely that CMS will change the allowed case mix adjusters on a yearly basis as they already to with payable DRGs we see in the inpatient and outpatient settings. With a fixed rate of payment and no compensation in kind for these hidden administrative costs, the setting is in place for competition of funds between administrative layouts and clinically required treatment costs. Without upfront costs adjustments for these hidden administrative costs, patient care is at risk of further decline in quality with the likelihood of adverse outcome increases in a population already at the highest risk of adverse outcomes in the western world.
I would suggest a simplified single payment without complex case mix adjusters as many private capitated contracts already do very successfully. The only winner with increased bundle complexity will be CMS itself which will need to add to their employment ranks to oversee the compliance of such a complex system. Those at the sharp end of the needle are at great risk of higher rates of complications due to competition between administrative costs and treatment costs. The current CMS bundle rule should be simplified to reduce and eliminate these new and hidden administrative costs while at the same time complying with the intents of MIPPA.
MIPPA legislation in 2008 mandated an expanded bundled payment system for Medicare dialysis patients. In doing so, the proposed rule will rely upon a higher base payment calculated to be about $198 with case mix adjusters to fill in any variations in costs between patients of higher or lower complexity. At the outset, this system appears to take advantage of social and medical factors that could lead to inequality in care among patients. However, what CMS has not addressed in any of their comments or discussions are the hidden administrative costs for physician and dialysis providers Medicare compliance.
Under current Medicare laws and regulations, the physician or dialysis provider must comply with all Medicare regulations and offer compliance training to all of their employees. As a physician who has undergone such compliance training and who has been involved in documentation efforts over many years, the unforeseen implications of the increased complexity of the case mix adjusters with the propose bundle rule will lead to increased time at the point of service for dialysis technicians, nurses, physicians, social workers, pharmacists and dietitians to remain in compliance with each pay per session data collection.Provider Risks for Fraud & Abuse (PDF link)
- Billing for services/supplies that were not provided
- Incorrectly reporting diagnoses or procedures to maximize payment
- Billing for services/supplies or writing prescriptions for drugs that are not medically necessary
- Remuneration schemes that unlawfully induce or reward the provider to bill for services/supplies or write prescriptions
- Provision of false information (e.g. falsifying info on a prior authorization request, misrepresenting dates of service, etc.)
- Unbundling charges
- Violating the assignment agreement, Fee Schedule, or Maximum Allowable Actual Charge Limits
The case mix adjusters also have several key inpatient factors that will need to have close data recall and sharing between inpatient and point of outpatient care parties. This will increase the secretarial administrative duties with the dialysis unit and most likely will be accomplished by added employee positions.
In addition, the physician who wishes to stay in compliance will need to update their training on an annual basis since it is likely that CMS will change the allowed case mix adjusters on a yearly basis as they already to with payable DRGs we see in the inpatient and outpatient settings. With a fixed rate of payment and no compensation in kind for these hidden administrative costs, the setting is in place for competition of funds between administrative layouts and clinically required treatment costs. Without upfront costs adjustments for these hidden administrative costs, patient care is at risk of further decline in quality with the likelihood of adverse outcome increases in a population already at the highest risk of adverse outcomes in the western world.
I would suggest a simplified single payment without complex case mix adjusters as many private capitated contracts already do very successfully. The only winner with increased bundle complexity will be CMS itself which will need to add to their employment ranks to oversee the compliance of such a complex system. Those at the sharp end of the needle are at great risk of higher rates of complications due to competition between administrative costs and treatment costs. The current CMS bundle rule should be simplified to reduce and eliminate these new and hidden administrative costs while at the same time complying with the intents of MIPPA.
Peter, thank you for posting this area of which demands attention and inclusion in all public comments.
Roberta Mikles, RN
Patient Advocate
www.patientsafetyday.com
www.qualitysafepatientcare.com
Posted by: roberta mikles | November 20, 2009 at 04:09 AM
I agree completely with your view. This past week I submitted my comments to CMS on the proposed bundle and asked that they take a step back and reimburse all patients at the same rate, and also to reconsider adding any additional labs or meds. They have cost and reimbursement information to determine a fair rate on these items, but when they start adding Part D meds and additional labs the amounts they are considering for reimbursement are too low in my population. It is also difficult to explain to patients why one has a higher rate per treatment than another patient - sometimes by as much as $100, and why the rate changes monthly. We all have a variety of patients to treat, and the difference will come out in the wash. Another administrative cost I am not looking forward to is collecting copays, not just on treatments, but labs and meds. The bundling should simplify claims and the claims process, not make it more difficult.
Posted by: Lori S. | November 21, 2009 at 01:29 PM
Is inclusion of Part D drugs not somewhat discriminating? It now seems with the inclusion of Part D drugs that those individuals with ESRD will have their Part D implemented different. This was NOT the intention when Part D was first initiated. Just seems so discriminatory
Roberta Mikles
Posted by: Roberta Mikles | November 21, 2009 at 03:00 PM
Clarification as I received a private email re post-----..
Medicare Part D is available to non-ESRD beneficiaries and ESRD beneficiaries now. However, in the proposed rule, with inclusion of Part D drugs, it seems that those with ESRD will NOT have the same Part D benefit as those non-ESRD beneficiaries, therefore, is this not somewhat discriminatory?
Roberta Mikles
Posted by: roberta mikles | November 21, 2009 at 06:22 PM