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September 15, 2009


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roberta mikles

Bill, Advocates4QualitySafeCare supports your statement "After the first read I'm wondering why not include unit mortality rates which are a part of DFC? And why not go beyond DFC and draw from the KECC Dialysis Facility Reports which include things such as hospitalizations and infections?" These two aforementioned are a MUST to be included.

One 'reality' question to ask is "How will delivery of care be affected by the new bundled rate, e.g. lab tests, medications, supplies, etc.?" Again, there is more to delivery of care than that which is on the Dialysis Facility Compare or included in the CPMs.

Roberta Mikles, RN, Director


I was surprised to see that the Quality Incentive Program measurements were apparently reduced to anemia management and Hemodialysis adequacy. The previous Report to Congress, "A Design for a Bundled End Stage Renal Disease Prospective Payment System", suggested many other measures, such as patient satisfaction, Iron, vascular access, bone and mineral metabolism, and others.

Richard Menard
Healthcare Business Analyst

roberta mikles

I think we all must remember, and keep in mind, that CMS is attempting to IMPROVE care and deliver QUALITY SAFE care. BUT ---What CMS needs to understand is that there is MORE to delivery of quality safe care than anemia management, dialysis adequacy and other CPMs. If a patient acquires an BSI and dies, what difference does it make if their anemia was appropriately managed or their blood was being cleaned? Truthfully, think about it. If a patient is hospitalized, loses their life, or has a severe negative outcome because of the wrong bath, lack of staff identifying a pyrogenic reaction, not following prescribed orders, not reporting to the RN symptoms that require further assessment or following facility policies and procedures,,, then, again what good is it to have those two areas as major areas in the QIP. What I have been stating for several years was recently basically reiterated by Dr. John P. Capelli of Our Lady of Lourdes Medical Center. His article in Nephrology News & Issues "Measuring the quality of patient care goes beyond just numbers" clearly sends a message not only to providers, but to CMS. I have continued to state that, perhaps, Medicare should do that which is done in hospitals and that is to withhold payment when certain preventable errors occur resulting in negative outcomes. When CMS only addresses anemia management and adeqacy as indicators of quality safe care, or sanctions a facility that is out of paramenters for same, but does not address other areas of care, especially infection control and infection rates, then something is drastically wrong. This is unacceptable and patients deserve more.
Roberta Mikles, RN, Director


The simplest solution, IMHO to the immediate question of quality measurement is to use the DOPPS-developed (and therefore research-based) "Practice Risk Score" (PRS) . This composite of anemia, adequacy, access, and albumin predicts mortality at the facility level. Why develop a new set of measures? Yes, these are all clinical. As someone who advocated for health-related quality of life to become a clinical performance measure, I'd love to see it included. As a pragmatist, that seems unlikely. At least CMS could choose the PRS, a measure that really makes a difference.

I was very pleased to see that reimbursement would be at the treatment level, could be for up to 20 treatments/mo. (with medical justification), and that longer and/or more frequent HD were mentioned. I was NOT pleased to see Congress'' requirement for a "98% budget neutral" bill, that results in the renal community LOSING a further $200 million--after decades of historical lagging because there has never been an annual update. And I was NOT pleased that home dialysis training was included in the bundle as "overhead"--a serious threat to home programs.

The addition of Part B & D drugs in the bundle is concerning. Having dialysis clinics responsible for providing folks' BP drugs, binders, vitamins, etc. could create a powerful incentive for better dialysis--which reduces the use of these drugs. Or, it could create a group of "second class Medicare beneficiaries," reduced to begging their clinics for drugs they need, and no longer able to obtain them otherwise unless they're willing to pay for them themselves. It's hard to say which way this could go...

More to come...

Denise Eilers

Although I am pleased that under the new bundle dialysis will be reimbursed per treatment, I am disappointed that the CMS rules do not include incentives for home treatment.

Just as KCP is set to launch its PEAK program (Performance Excellence and Accountability in Kidney Care) with a goal to reduce mortality among first year dialysis patients by 20% by the end of 2012, CMS has chosen to ignore mortality as a quality marker.

I also wonder how quickly Quality of Life would be used as an indicator if some people at CMS were dialysis patients.

Denise Eilers, BSN, RN

roberta mikles

Denise, our group has been discussing such (incentives for home treatment) considering all know that quality of life is improved, along with other advantages when doing HHD.
Roberta Mikles, RN, Patient Advocate

Denise Eilers

Roberta, You are preaching to the choir. My late husband was a home hemodialysis patient for just shy of 25 years, so I can attest firsthand to the benefits of home treatments. I totally agree with you about improved quality of life. CMS needs to realize that labs are only one piece of the puzzle.

roberta mikles

Denise, please feel free to contact me as I am willing to support whoever feels the same.


Anyone here plan to attend (and speak) at the Town Hall Meeting on End-Stage Renal Disease (ESRD) Perspective Payment System on 10/23/2009 ?


roberta mikles

If I am correct, one has to be there in 'person' which is greatly limiting to many. If I am incorrect, please let me know. It would be great if it were such as an 'open-door' forum, whereby all who had comments, concerns, and opinions could participate. Again, when such is limited, as 'in-person attendance' it prevents many from participating.
Roberta Mikles, RN
Patient Advocate

Bill Peckham

I'd be interested in hearing from someone who has attended one of these in the past. I think so far as the proposed rule goes commenting online is as effective as commenting in person. CMS is in an official comment period - how or when you submit a comment doesn't add or take away from the weight it is given.

It would be interesting to live blog the meeting - the comments are sure to give a pulse of the industry.


Only 381 spaces left.


Let me see if I have this correct: with the new bundling system, since it is per treatment and Medicare recipients are obligated to pay 20% of the cost, then every hemodialyzor who is on Medicare but not on Medicaid is obligated to pay a minimum of $475/month for dialysis?

This rises to something on the order of $750/month minimum if the dialyzor is on home dialysis and dialyzes the maximum times per month that Medicare will cover?

How is one supposed to afford that? It would quickly bankrupt us.

Washington state is one of the states where one apparently cannot buy a Medicare supplemental policy as an ESRD patient under 65. Thus, any Medicare patient under 65 would be on the hook for large sums of money every month in co-pays. Is the patient objligated to spend and spend and spend until he or she is destitute enough to qualify for Medicaid assistance?

And does anyone know how, if at all, this new rule affects PD?

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