By Bill Peckham
By my count 584 comments have been submitted to Medicare in response to the ESRD Prospective Payment System Proposed Rule (you can view the comments here or download the continuously updated Excel file). I've read all the comments; the passion for the dialysis program and patients comes through above all. However, I'm concerned that for all the passion the commenters aren't closing the deal. The comments aren't closing the deal because many are not including an actionable solution.
The number one topic of commenters is the inclusion of oral drugs in the new dialysis payment. There is a lot of passion around not including oral drugs, with many commenters mentioning logistical concerns, patient compliance and inadequate reimbursement as reasons oral drugs should be left out of the bundle and many predict an increased prevalence in secondary hyperparathyroidism as the inevitable consequence of units controlling costs by using inexpensive and less effective drugs. And that is as far as many commenters get.
Without offering Medicare a concrete step they can take to avoid these bad clinical outcomes, without offering a solution, the commenters are leaving it to Medicare to both want to solve the problem and know how to solve the problem. It would make life easy if a chorus of boos was all it took to keep oral drugs out of the bundle but unfortunately the tide is running the other way.
The House of Representatives' health insurance reform bill - HR 3962 - mandates the inclusion of binders and calcimimetics in the dialysis payment bundle. If Congress passes a law that oral drugs are included in the payment then Medicare must follow that mandate. A larger bundle is the direction the world is going; a commenter should acknowledge this reality and then close the deal with an actionable suggestion. In the case of oral drugs the actionable suggestion is: to wait. CMS (and Congress) should wait a few years before adding oral drugs into the bundle.
Wait until dialysis providers have fully implemented the changes that are mandated by MIPPA. Wait until the fair cost of these relatively new drugs can be accurately judged. Wait until appropriate quality measures are established. Wait so that providers can adjust their operations to accommodate other recent administrative and clinical challenges e.g. CROWNweb, the Conditions for Coverage. Wait until health reform is passed: so that we can understand the implications for the donut hole and the cost of drug access under the new law. If CMS takes that action, if CMS waited ... that would be a good outcome. I don't think "no oral drugs ever in the bundle" is on the table; a prudent delay would make this rule better.
Waiting isn't never. Given time Medicare will be able to evaluate other options to calculate the average cost of these dialysis specific oral drugs and then add a fair amount to the base payment rate. The methodology used in the proposed rule spreads the binder and calcimimetic 2007 Medicare reimbursement costs (largely Part D spending) across all patients. 2007 is not an appropriate base year, and what to do about those who are Part B primary but have drug coverage outside of Part D?
Action: Medicare should wait and establish the base year after healthcare reform increases access to these dialysis related oral drugs and once the average cost per well managed beneficiary is known.
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