My Comment to CMS on the Proposed Physician Fee Schedule for MCP Physicians

By Bill Peckham

The deadline to submit comments on CMS's proposed payment policies for the ESRD Monthly Capitation Payment to physicians who are following home dialyzors is NOW. Comments are due by 5PM EDT tomorrow, Tuesday August 24th. What follows are my comments on the proposed rule:

Dr. Donald Berwick
Administrator
Centers for Medicare and Medicaid Services

RE: Codes 90963-90966 under CMS-1503-P: Proposed Rule for Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2011

Dear Administrator Berwick:

Dr. Berwick when you were nominated to head CMS you were quoted saying something that is very wise:

The best health care is the very least health care we need to gain the long, full and joyous lives that we really want. The best hospital bed is empty, not full. The best CT scan is the one we don’t need to take. The best doctor visit is the one we don’t need to have.

Indeed.

Dr. Berwick you gave voice to my experience and something I believe is often true among people who use home dialysis. Missing an appointment can be a sign of health. Of success. The physician fee schedule should allow less than perfect adherence to the best practice of monthly visits. CMS should accommodate, rather than punish, success at home. I urge you to maintain current policy.

I live with stage 5 chronic kidney disease (CKD5), and have been a Medicare beneficiary under the ESRD Entitlement since 1988 when I had a preemptive transplant (I was 24 at the time; 46 today). My underlying condition - FSGS - recurred after just 26 months. Since September 1990 I have treated my kidney disease with hemodialysis (HD). Initially I used conventionally incenter HD but for the last nine years, since September 2001, I have enjoyed using a healthier, more frequent dose of HD in the comfort of my home.

I would like to offer a comment concerning the language, in Section C.1. (p 219-224) of the proposed rule, with its firm requirement for a monthly face-to-face visit as part of codes 90963-90966. I am a HD advocate and as a member, have joined a comment submitted by the Home Hemodialysis Workgroup, these additional comments are less big picture; based on my extensive personal experience.

I believe this no exceptions policy will be unfair to the dwindling number of MCP nephrologists willing to follow home patients.

I agree that it should be routine and is a medical best practice to see my MCP physician every month but a perfect attendance record is hard to achieve and unreasonable to expect. My doctor and I are in this for the long term – it would not have been fair if a 90% attendance record over the last nine years had resulted in my doctor not being paid a dozen times. Under the proposed rule my inability - due to travel, work, or family obligations - to keep an appointment would cause my doctor to pay a price. This is unfair.

Life happens. Particularly for those of us getting a higher dose of dialysis at home, it's good news. We feel well enough that other elements of our lives have higher priorities than seeing our doctor. It is a sign of health and optimal dialysis when our medical needs are no longer our highest priority and we feel well enough to live the lives we were meant to live.

When I feel unwell or have medical issues to resolve I will give seeing my doctor a high priority. Month to month, seeing my doctor is given the priority of the routine: one of life's tasks that needs to be done every month, like paying bills. That's healthy. This rule would require that I give my doctor appointments the highest priority which is inappropriate.

I routinely organize my work schedule to accommodate an appointment (note as a union worker I'm off the clock when I am at the doctor's office) but it is possible, and over a period of years likely, that my obligations as an employee, that my obligations to my employer, will trump the need to keep a routine doctor's appointment. To make my doctor pay a price for this healthy situation would be unfair.

It would be doubly unfair because my doctor is following my care even when I miss the appointment. Every month, day in and day out he is available to me and my provider, he is still reading my labs and coordinating changes in my treatment with my unit. Given this baseline of work that occurs day in and day out it is not unreasonable to continue to support the MCP physicians of healthy, thriving patients when the patients miss their appointments.

CMS should accommodate, rather than punish, success at home. I urge you to maintain current policy

Thank you for your consideration.

Hopefully the final rule will not do anything to limit access to home dialysis. You can submit your comment online.

Comments

[Miriam Lippel Blum]

Bill,

My nephrologist said that he does "face to face" visits with his rural patients via Skype video conferencing. He insists this is acceptable to Medicare. If this is true then why couldn't it apply to all HHD dialyzors? Or is he mistaken?

I wouldn't have a problem with doing a quick appointment with him via Skype instead of shlepping into his office. Do you think the new bundle working regarding doctor visits would preclude this?

Miriam

[Rich Berkowitz]

Miriam, the proposed rule stipulates in person face-to-face.

[Bill Peckham]

Part of the proposed rule that I didn't comment on expands telemedicine to predialysis CKD patients. I think if the rule is finalized as is, docs will be able to provide the 6 CKD4 consults provided for under MIPPA via telehealth.

I didn't suggest any solutions in my comment because I don't really understand the doc reimbursement process in full. I'm not sure I would want telehealth to replace the face to face visit but I do think it can be used to good effect.

Via email it was pointed out that I may have been too quick to accept even the monthly requirement as medical best practice. There have been times over my nine year home career (as of 9/25) when I didn't need to and didn't see my doc for months - while traveling certainly.

I do think with frequent (particularly nocturnal) dialysis a person can reach the point where monthly visits are a waste of time. Leaving the policy as is would be most prudent.

I think current policy would allow skype in the sense it does not now require a face to face for home dialyzors. Thus payment is the same whether you skype or not so in effect the doctor is free to use skype in place of face to face by her judgement, for example for rural patients. That sounds like good care to me and CMS should be willing to reimburse for that.

[David L. Rosenbloom]

Amen, Bill. I couldn't have said it better. The prime idea behind home dialysis, not unlike a transplant, is to regain control over one's life and live it fully, making accommodations for health, but not letting CKD define one's life entirely. Too often kidney professionals view dialyzors as invalids, who no longer work but live soley from treatment to treatment.

Even today, two years after a successful transplant, I rarely see my nephrologist, who has become my primary physician, more than once every 6-8 weeks. There is no need. I get my blood drawn on the same schedule, review my labs with him, and we make adjustment on meds as needed. No big deal. If something comes up that I feel needs his attention, I email him and hear back from him or his nurse within 48 hours. He is intelligent, diligent and caring, and I trust him. He deserves to be paid no matter how I communicate with him. He is on the job full time.