HR 3962 mandates the inclusion of binders and calcimimetics in the dialysis payment bundle

By Bill

Given all the rending of garments and gnashing of teeth over Medicare's proposal to include oral drugs in the new expanded dialysis payment mandated by Congress, I expected a similar reaction to the ESRD section of the House health insurance reform legislation, H.R. 3962: Affordable Health Care for America Act. Instead, I have seen no reaction at all to the legislative language that would mandate Medicare include oral phosphate binders and calcimimetics in the new per treatment payment for dialysis.

I have heard broad support for the first part of H.R. 3962's ESRD section which would extend immunosuppressant drug coverage to those that would otherwise loose Medicare coverage three years after transplant. That's a long overdue change but does the ying and yang of Washington require every good idea to be balanced by a bad idea? No matter what Medicare decides in response to comments, if the House language stands oral drugs will be in the bundle (link):

(b) Medicare Coverage for ESRD Patients- Section 1881 of such Act is further amended--

(1) in subsection (b)(14)(B)(iii), by inserting ‘, including oral drugs that are not the oral equivalent of an intravenous drug (such as oral phosphate binders and calcimimetics),’ after ‘other drugs and biologicals’;

(2) in subsection (b)(14)(E)(ii)--

(A) in the first sentence--

(i) by striking ‘a one-time election to be excluded from the phase-in’ and inserting ‘an election, with respect to 2011, 2012, or 2013, to be excluded from the phase-in (or the remainder of the phase-in)’; and
(ii) by adding before the period at the end the following: ‘for such year and for each subsequent year during the phase-in described in clause (i)’; and

(B) in the second sentence--

(i) by striking ‘January 1, 2011’ and inserting ‘the first date of such year’; and
(ii) by inserting ‘and at a time’ after ‘form and manner’; and

Including oral medications in the bundle is represented as a way to pay for immunosuppressant drugs but that doesn't make sense.

To include binders in the bundle Medicare would take all the money spent on binders through Part D, divide by the number of treatments and add that amount to the base payment rate (after figuring the impact of case mix adjusters). In other words it is a budget neutral process. The problem with this is that if the payment was fair then it wouldn't be budget neutral (let alone save money).

This provision would cost money because many people who are Medicare primary for Part B services have their binders paid for by a private insurer outside of Medicare Part D. Since under this provision they would have their binders supplied by the unit and reimbursed through the per treatment payment - you have to ask where is that money suppose to come from? Either Medicare would have to reimburse more or it is an unfunded mandate that will result in more hospitalizations and worse outcomes.

I'm all for immunosuppressant drug coverage but including oral drugs in this ham handed way is bad for dialysis patients, without any obvious benefit to Medicare or taxpayers. Hopefully the Senate can propose a sensible alternative.