In September of 2009, the Center for Medicare and Medicaid Services (CMS) developed a proposed outline of a new payment system of dialysis services commonly referred to as “bundling.” This new payment process affects individuals who are on dialysis. The nearly 600 page document has been the topic of many deliberations. The American Association of Kidney Patients (AAKP) was involved in many discussions and its Public Policy Committee spent time reviewing the document to assess its effect on patient care.

With this proposed piece of new legislation being discussed last year, as a patient, you may be wondering the following:

• How can I better understand the bundling process?
• How may it affect me – the patient?
• Was the patient voice heard? 
• When can I expect changes to occur?

How Can I Better Understand the Bundling Process
Per the Medicare Improvements for Patients and Providers (MIPPA) Act of 2008, this new law required payment for pre-dialysis education along with a new payment system for dialysis services – “bundling.” This new payment process bundles or groups together services such as dialysis treatment, certain routine drugs and laboratory tests and supplies furnished at home or at an in-center dialysis facility. A few goals of bundling dialysis services are to make the Medicare reimbursement process for dialysis providers (the payment dialysis facilities receive from Medicare for services) easier and more efficient while maintaining quality patient care.

How May It Affect Me – the Patient
While AAKP supports the shift of the Medicare payment process to increasingly focus on high value care, it also expressed concerns that without thoughtful consideration and appropriate oversight, these changes may increase barriers to care for some people with kidney disease.

AAKP sent a detailed letter to CMS outlining its concern that this new bundle payment could limit access to care for patients who might unknowingly decrease the amount Medicare reimburses for dialysis services. The Association explained how a patient who medically requires more drugs and/or laboratory tests not included in the new bundling system may not be accepted for treatment in facilities trying to increase their profit and make more money, because the doctor or dialysis facility might not get reimbursed correctly for the extra drugs or laboratory tests administered. Any system that links financial incentives or financial disincentives with limiting access to health care for certain types of patients can easily cause “cherry-picking” of the perfect patient who will make dialysis providers the most money.

Additionally, the bundling of laboratory tests reimbursement ordered by a physician in the dialysis unit will likely result in dialysis patients needing to go to labs on their off dialysis time to get blood drawn for tests that are not reimbursed like when blood is drawn in a dialysis center. Dialysis patients may also need to go to pharmacies during off dialysis time to get prescriptions for medications that were previously given in the dialysis center. Not only will more time be spent on off dialysis days getting laboratory tests and medications, but co-pays for these services will also be required whereas previously they weren’t, because the services were provided in the dialysis center. This process can unintentionally impact a patient’s quality of life by causing them less free time and more time spent taking care of health care issues. It may also lead to patients spending more money, because of additional co-pays.

Another point of concern that should be addressed is the following – during the first four months a patient begins dialysis, the reimbursable amount to the dialysis facility is greater since an educational component is included in these first few months to help the patient understand their condition, the process of dialysis along with various treatment options. AAKP is concerned that patients might not be provided with adequate education on all the various treatment options such as home dialysis and transplantation in a timely manner, because the dialysis facility would, in a sense, “lose” money if that patient chooses another option other than in-center dialysis.

Was the Patient Voice Heard
The answer to this question is – YES! With the potentially negative side effects this new piece of legislation might create if enacted as proposed, this has been a common question among patients. Upon public release of the proposed bundling process, CMS sent out a call for comments. The general public, patients, health care providers, organizations, associations and corporations were invited to share their thoughts and concerns. The community had until Dec. 16 to submit comments to CMS. AAKP sent a letter addressing its concerns while continually enforcing that equal access to the best patient care is essential. AAKP also hosted a HealthLine teleconference educating the public on this bundling process and encouraged patients to contact their representatives. Contact information was posted on the AAKP website with a direct link to submit comments to CMS. With the help of patients and the entire renal community, we believe our message of quality patient care and quality of life was heard.

When Can I Expect Changes to Occur
CMS is expected to announce a finalized bundling payment process by Jan. 2011. Once approved, it is estimated to take four years for this legislation to be fully carried out. For the latest information on the bundling payment process or to view the proposed document, visit the Center for Medicare and Medicaid Services, website at www.cms.gov/center/esrd. To view AAKP’s comments to CMS visit www.aakp.org/public-policy/PPS.

Richard Goldman, MD, is a retired nephrologist from Albuquerque, NM. He serves on the ESRD Network 15 Board of Directors and is active in the Renal Physicians Association. He is also President of the Forum of ESRD Networks and serves on the AAKP Board of Directors.

Paul Conway, is a former peritoneal dialysis patient and current transplant recipient from Falls Church, VA. He serves on the AAKP Public Policy Committee. Until recently he worked as the Acting Federal Coordinator and Chief of Staff for the U.S. Department of Homeland Security, Office of Gulf Coast Rebuilding. Mr. Conway was also the Chief of Staff to Federal Coordinator General Douglas O’Dell and Chief of Staff to Federal Coordinator Donald Powell.

This article originally appeared in the July 2010 issue of aakpRENALIFE.

Posted 8/10/2010.

Back