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August 26, 2009


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Peter Laird, MD

Bill, I agree, it was a very productive and informative meeting. Bill and I have always seen eye to eye on optimal dialysis and that is why Bill has put up with me this last year I am sure. I believe the label of conservative or liberal is just that, a label that does not in any manner tell the entire story. The issue is not politics, but saving lives and giving people a chance to live as best as anyone can once diagnosed with CKD. The issue of the new bundled payment system could be a defining moment for CMS and how they consider treatment at home and other forms of quotidian dialysis. The response from the renal community will be key.

There are many aspects of the bundling system that could lead to lower treatment outcomes if not considered carefully. My outlook after learning about the bundle indepth at this meeting is that CMS could improve outcomes simply by incentivizing home, daily dialysis by paying per treatment rates in the bundle. If the bundle comes in the form of a weekly or monthly payment, that will incentivize reduced frequency and duration of treatment which we already know leads to the early death of many that could live longer and better with optimal dailysis.

Lore Hartwell and RSN is doing this in preparation of a 60 day period of time to respond to the bundling rule when it is released. The devil will be in the details. My hope is that the direction of change as outlined in the Harvard letter to Obama as well as the RSN letter will give CMS the political courage to end the shame of our last place mortality outcomes in our dialysis centers. Ultimately, whatever congress and CMS do about the ESRD program, nephrologists are the only people that actually write prescriptions for dialysis. The bottom line responsibility is in their hands alone. It is my hope that we can exceed the outcomes of Japan and other nations that have less than half of our complications and deaths. The time has come.

Lori Hartwell has accomplished much with her organization and I look forward to seeing what else she will be able to overcome in the next few months. The need is great and the workers are few. Of course, if CMS adopted the same outlook on optimal dialysis that RSN and DSEN have, we could all fold up shop and enjoy our time doing other activities. In the mean time, I look forward to working for the common goal of optimal dialysis in America. It makes sense medically and economically. It's time has come.


"The price of freedom is eternal vigilance."
-- Thomas Jefferson

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