Dialysis from the sharp end of the needle

Come see Rogue rafting pictures and video at Seattle area CKD meeting August 29 - register now!

By Bill Peckham

If you're in the Seattle area on August 29th plan to attend the Renal Support Network's 2010 Seattle Patient Lifestyle Meeting. I'll be speaking about travel - most recently the trip with NxStage down the Rogue and the first NxStage Freedom cruise last January, but also my 15 years of foreign hemodialysis travel experience. And if there is time a little about bundling.

The PLM is free for you and a guest to attend, please RSVP by August 20th. You can RSVP in two ways:

• Fill out the form ( PDF link) and fax it to: (818) 244-9540
• Register online at RSNhope.org

And I'm not the only speaker!

The Key Note this year is Dr. Connie Davis a University of Washington professor of medicine,the director of kidney care and transplantation services at UW Medical Center and both co-director and medical director of the kidney and pancreas transplant program at UWMC. Dr. Davis is a great resource for anyone considering a transplant.

As always the agenda is subject to change:

Seattle Patient Lifestyle Meeting
Agenda

•  9:45      Registration, Brunch, Visit the Exhibits and Silent Auction (to benefit RSN)

• 10:45     Welcome, Introduction and Door Prizes       
  
  • Bonnie Markuson, kidney patient
  • Sharon Pahlka, CLC, kidney patient

• 11:00     Keeping Fit with CKD and the Benefits of an Early Transplant
  • Connie Davis, MD, UW Medical Center, Division of Transplantation

• 12:00     Spicing Up Your Renal Diet
  
  • Maya West, Renal Dietitian, Northwest Kidney Centers

• 1:00       Understanding Your treatment Options and Planning Your Course
  
  • Sandra Glenn, RN, BA, CNN

• 1:30       Going Rogue and Other travels with Dialysis
  
  • Bill Peckham, kidney patient

• 2:45       How Do I Ask for a Kidney?
  
  • David LeFevre, Kidney Donor

All that and a tasty buffet. And did I mention it was free!

Bill Peckham to keynote Portland Patient & Community Education Symposium March 14

Bill Peckham

If you're not in the Seattle area for the NxStage event, come to the National Kidney Foundation's Patient & Community Education Symposium in Portland on March 14th (download a conference brochure PDF here). The event is from 10AM to 4PM; my talk is at 11AM, Lessons in Living with Kidney Disease — Hope, Challenge and Adventure. I should be able to cover that with a bullet point free PowerPoint presentation in about 30 minutes. That will leave time for a couple questions.

To attend this free event, or for more information, contact Scott Howard, at (888)i-ask-NKF/(888)427-5653 or scott.howard@kidney.org.

My comments to the CMS Town Hall meeting on ESRD Prospective Payment System Proposed Rule

By Bill Peckham

I was given the opportunity to present oral comments to the CMS Town Hall meeting today. Speakers (PDF link) were limited to five minutes and many of hit us the same points. I hope to be able to post and/or link to some of the other remarks, here are mine (lightly edited):

Good morning everyone. I wish I was there with you but I am grateful for the accommodation that is allowing me to address you from my home. I'm Bill Peckham.

I have been a Medicare beneficiary due to ESRD since July 1988 when at age 24, I received a kidney from my oldest brother.

My underlying condition - FSGS - recurred in the transplant; I started dialysis in September 1990. After first dialyzing incenter I switched to home dialysis in September 2001. At home I enjoy a healthier, more frequent dose of dialysis. I currently dialyze five nights a week, over night, while I sleep.

I appreciate the opportunity to comment on the ESRD Prospective Payment System Proposed Rule. My comments are grounded in my belief that all Medicare beneficiaries with severe kidney disease should be able to live the lives they were meant to live but for their bum kidneys.

I know dialysis works. As I read through and thought about the proposed rule I asked myself:

Will this proposed rule increase or decrease the burden of dialysis on those who are ill?

After many hours of thought and deliberation, numerous conference calls and meetings … I don't know the answer. I don't know what all this rule will do but I have concerns. It is a big change! Including Part D medications?!? Really? As the kids say OMG.

I am a  payment policy hobbyist. This is my avocation, not my occupation. And this was a lot to evaluate. I am not entirely confident in my understanding of each of the many elements in this proposed rule. Some things I'm sure of; other things not so much.

First, the thing I am most sure of is the need for a separate home dialysis training payment modifier. Home dialysis training is not a routine service. It is expensive and right now access to home training is limited by insufficient training capacity.  

Including training in the base rate will further constrict access to home dialysis. Each training session should be paid at a level commensurate with the amount of one-on-one nursing time training requires.

Second I am confident  that this rule would be improved if covered labs were defined on a list rather than defined as those ordered by the MCP.

My nephrologist (who receives the Medicare Capitated Payment each month) should also be able to act as my primary care doctor. This came up this summer when I had a cancer diagnosis. I would not have wanted to endure the added appointments this proposed rule would have required. Non ESRD labs, drawn in the unit, should be paid outside of the ESRD bundle.

Having routine labs defined by a list would also better accommodate travel. Labs related to travel should be specifically excluded from the bundle – travel is important, please don't make it harder.
 
In general I think the complexity of the new rule will drive further dialysis provider consolidation, in an already consolidated industry. I think ownership diversity is healthy. I don't understand CMS's choice to define small volume facilities in terms of patient census rather than in terms of the size, and therefor the purchasing power, of the provider.

CMS should define “small volume” as units owned by providers who serve fewer than 1% of the total dialysis census. This would help slow the rush to oligopoly by giving truly small providers additional resources to operate under the new payment rule.

I doubt anyone can fully predict the impact of having dialysis units administer oral medications. It's too big a change. In the face of this uncertainty I urge Medicare to be constrained by prudence. Simplifying the rule would be prudent and also would help small providers cope with this far reaching change. Do not expand the bundle beyond what is required by MIPPA. Scale back the complexity.

This is an historic change that will guide and constrain the provision of dialysis for a generation. It's critical to get this right. I urge caution. Thank you.

Those five minutes went by fast.

I've long seen that dialysis provider size was a key factor in the move to expand the dialysis payment bundle. My belief in the value of nonprofit community based healthcare was in my mind as I spoke in favor of provider diversity. However, one of the speakers, Mrs. Diane Crafton, of Wheeling Renal Care, LLC, gave compelling remarks about the importance of supporting small providers that really spoke to the need to define "small provider" in terms of patients served or treatments delivered. A small provider should be a provider that delivers fewer than 1% of all dialysis treatments.

Have PowerPoint, will travel

On Friday last week I gave a 40 minute presentation to the Puget Sound chapter of the American Nephrology Nurses Association (PS ANNA). This presentation grew out of a presentation I gave last November at a national meeting of the Kidney Community Emergency Response (KCER) Coalition Pandemic Preparedness team. At the KCER meeting I presented NKC's pandemic preparations. At the PS ANNA meeting I presented NKC's preparation and my own personal pandemic influenza preparation - what does robust personal pandemic preparation look like for a dialyzor?

At both meetings Dr. Koelemay from King County Public Health spoke giving the pandemic flu background piece, including how emergency operations are structured in King County, WA. Dr. Koelemay's presentation is a nice segue into the NKC and personal piece of the pandemic preparedness puzzle because the majority of NKC's service area is in King County and the county emergency management organization is the correct level of government for a dialysis provider to connect with, at least here in Washington state.

Between slides available through KCER and through various pandemic preparation websites I could give the complete pandemic preparedness presentation. Four other presentations that I can give (have given in the past) are the Northwest Kidney Centers; Travel; Home Hemodialysis; and the Dialysphere.

I will travel to participate in meetings. I'll be going to Dallas on the 3rd of April and Cleveland later in the month. As far as rates I would like to receive my union hourly which works out to $200/day plus travel expenses. Flying to Cleveland or Dallas will require two days but meetings on the west coast can often be scheduled to avoid the need for an overnight.

If pandemic planning isn't on your radar, it should be; give me an hour to explain why.