In September, the Centers for Medicare and Medicaid Services (CMS) issued proposed new rules on how physicians will be paid for dialysis services. The nearly 600 page document has been the topic of many deliberations. The community had until Dec. 16, 2009 to provide comment. Below is AAKP’s response.
December 15, 2009
The American Association of Kidney Patients’ (AAKP) main focus for the past 40 years has been to ensure quality of care and access for all dialysis patients and potential dialysis patients. We thank you for the opportunity to share our comments regarding CMS 1418-P. Our nation has the unique opportunity to provide better outcomes for kidney patients – and this can lead to substantial cost savings because better outcomes translate into less reliance on the drugs, dialysis and hospitalization currently covered by Medicare.
AAKP recognizes the detailed work that went into devising the ESRD Bundled Payment System Proposed Rule. AAKP has supported the effort to shift Medicare payment systems to increasingly focus on high-value care. But, we are concerned that without thoughtful implementation and appropriate oversight, these changes may increase barriers to care for individuals with kidney disease.
Access to and Costs for Medications and Diagnostics
Patients’ access to their medications and diagnostic tests is one of AAKP’s greatest concerns. It is not uncommon for dialysis patients to see their nephrologists as they would a primary care physician. With only ESRD related health care issues and medications covered in the bundle, there is the concern about the possibility of patients having to go to primary care physicians or other specialists for items such as insulin or cardiac medications. This means patients on their off dialysis days will be spending time going for laboratory tests and/or appointments for services that could have been provided, and previously have been provided, in dialysis centers. This additional effort impacts quality of life. For in-center patients on a thrice weekly dialysis schedule, time outside of a clinic or physicians office is cherished. Further, by requiring kidney patients to seek care from multiple providers for their health care needs carries the risk of repetitious testing, additional costs and potential confusion for patients accustomed to receiving primary care from their nephrologist.
There is also concern regarding the potential to underutilize bundled drugs and/or diagnostic tests thereby compromising patient safety and outcomes. With performance measures only initially focusing on adequacy and hemoglobin there may be unintended consequences caused by limited access to certain drugs. If the proposed payment system goes forward as outlined, we ask for a system that uses quality indicators to objectively validate care and identify issues that need to be addressed and fixed in a timely manner.
Patients are also concerned that in efforts to conform to budgetary constraints and still utilize those pharmaceuticals that allow the best clinical outcomes, funds will not be available to compete with other disciplines for the best nurses, social workers and dietitians. This could lead to health care which seeks a goal of meeting minimal standards.
There is obviously concern from patients regarding the financial cost to them as a result of the separate services described above. There is no methodology for capturing the additional burden of co-pays to the patients and we are willing to work with CMS to try to develop some type of monitoring system to minimize or prevent these occurrences.
Performance Measures
The science of medicine generally does not fall within the category of one size fits all. This is also true for using select and limited performance measures to evaluate patient care. While performance measures and careful oversight are appropriate for the proposed payment system, there is the potential for financial incentives and disincentives which could lead to cherry picking. A patient who medically requires more previously unbundled medications and/or diagnostic studies may not be accepted for treatment in facilities trying to maximize their margin. This scenario could potentially hold true for patients who have been labeled as “nonadherent to medical advice” or “having a disagreeable temperament.” There is the potential for facilities to refuse admission or readmission to patients when they have been a transient patient, in the hospital or in a rehab hospital for a number of months. In addition, individuals who use catheters for vascular access often have lower Urea Reduction Rations (URRs) and hemoglobin levels and therefore have the potential for lowering the performance score of a facility.
Only focusing on URR and hemoglobin is not a true representation of patient care. As CMS moves to expand the performance measures over time, there are more than 20 measures available to calculate how well a dialysis facility is providing care. Certain measures have been approved by the National Quality Forum and adopted by CMS. AAKP asks for CMS to consider adding measures of patient satisfaction; quality of life; education about options, disease and medications; and patient safety.
Adopting a measures-centric model of patient care will take planning and careful consideration. There is concern that nurses and other staff will spend increased time documenting performance measures. While the measures are important, the task can compete with direct patient care time, which may result in a decreased ability to answer patient questions and contribute to important patient education.
Access to Home Treatment Therapies
Retaining the per-treatment payment schedule and payment for up to three treatments per week, unless medically necessity justified more than three weekly treatments, demonstrates forward-thinking planning for treatment advancements. This also confirms AAKP’s belief in the time-honored principle that a physician and patient must be permitted to decide a care plan best suited for that patient because medicine is fundamentally about the treatment of a unique individual.
Inclusion of the home training fees within the bundle, however, may inadvertently have a negative effect on home treatments. Time intensive one-on-one training is required in order to safely send a patient home on dialysis. If this training is not considered, the patient is the one who is potentially negatively impacted, either by incomplete training or denial of access to all modality options. With the continual advancement of treatment options and outcomes, AAKP’s believes strongly a patient should have equal access to modality treatments.
While the case mix adjustment for vintage on dialysis is justified, it also has the potential to limit patients’ access to home treatment, including dialysis and transplantation. The first four months on dialysis provides a financial incentive for facilities to keep patients on in-center hemodialysis as opposed to referring to a home treatment modality. It also has the potential to decrease referrals for transplantation. Ultimately, if this occurs, the patient is again negatively impacted because of not having equal access to all modality options. As requested previously, developing a method to measure patients’ education about modality options will assist to capture unintended consequences with the case mix adjustment for vintage on dialysis.
Conclusion
ESRD health care has changed significantly since the initiation of the Medicare ESRD Program. We have witnessed many treatment modality and medication advances in ESRD care. It is essential that all patients have equal access to the best treatment available. AAKP supports the development of mutually agreeable economic arrangements between payors and providers for all medically approved therapies thereby providing fair and equal access for all patients. AAKP urges CMS to compensate fairly for all components within the bundle and initiate appropriate controls to guarantee these issues are addressed and minimized to ensure equal patient access to high-quality care.
We applaud your direction over the years on these issues so important to kidney patients. Our government can vastly improve the quality of care for kidney patients while saving money in many areas. Thank you for providing the opportunity for AAKP to share its comments.
Sincerely,
Roberta Wager, RN, MSN
AAKP President
This article originally appeared in the January 2010 issue of aakpRENALIFE.
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