By John Schall, MMP

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) became law when both Houses of Congress overrode President Bush’s veto of the bill in July. MIPPA makes far-reaching changes in the Medicare ESRD Program – including important improvements in the program that AAKP has long been calling on Congress to enact. This year our voices were heard!

Kidney Disease Education and Prevention
The law establishes new pilot projects to increase public and medical community awareness of chronic kidney disease (CKD) and to increase screening for CKD. The pilot projects will also test surveillance systems to improve how we assess the prevalence of kidney disease.

The law also creates a new education benefit for pre-ESRD patients. This is the first time ever such activities will be covered by Medicare. The goal here is that hopefully patients can delay onset of the need for dialysis. And when they do need dialysis, they will be better informed about their options between home and in-center dialysis, as well as the importance of getting a fistula. A fistula creates a vascular access used for dialysis rather than a catheter. Fistular access is clinically better, but you have to get it before you actually need dialysis.

Bundling Payments
The new law modernizes the Medicare reimbursement system for ESRD by moving to a bundled payment by 2011. Under a bundled payment system, the dialysis provider will receive one payment for both the dialysis and related drugs and lab services. This reform has been a longstanding recommendation of both the Medicare Payment Advisory Commission and the Government Accountability Office.

AAKP advocated for bundling out of concerns for patient care. Research now shows when ESA is used to raise red blood cell levels too high, it can put dialysis patients at risk of death or cardiovascular disease. Because of this, the FDA put a black box warning on ESAs last year.

Unfortunately, under the current system where ESAs are reimbursed separately, providers have a financial incentive to dose ESAs higher, with the ensuing health risks. A bundled system, however, will realign the system so dialysis centers have an incentive to be more efficient providers of care – including more efficient and appropriate use of ESA. The financial incentive to raise dosing levels will be eliminated.

Of course, under a bundled payment system, there must be strong protections in place to make sure every patient gets the care they need. Bundling cannot be “one size fits all.” It must be able to respond to individual patient needs.

To ensure proper care for Medicare beneficiaries with more complex needs, the law puts in place protections to ensure every patient will get the ESAs necessary to manage their anemia. First, the bill requires case mix adjustment, which adjusts payments upwards for more complex patients with higher costs of care. Second, the bill requires additional reimbursement to help providers cover the expense of high-cost outlier patients. Third, the legislation requires providers of ESRD services to meet a certain standard for quality of care, and cuts payments for providers who don’t.

Quality Measures
It is critical bundling have a strong quality component to ensure patients are receiving appropriate care. The good news is that for the first time ever there will be quality incentive payments in the ESRD Program. The bad news is the initial anemia management quality measure in this bill is not strong enough.
The quality measure tells providers they are providing acceptable anemia management care as long as they haven’t gotten worse than their past track record. This is wrong. We should be encouraging providers to improve the care provided.

There are serious health issues at stake, as we know from the FDA warning. But the measure in the law gives providers a pass as long as their anemia management care in the first year doesn’t get worse than past performance. Clearly there is more work to do and AAKP will closely monitor it to make sure it is done right.

Overall, this has been a great year for accomplishing important policy changes for the ESRD program. These are big steps forward in improving dialysis services to kidney patients across the country. We especially thank Congressman Pete Stark (D-CA), Chairman of the House Ways and Means Health Subcommittee, who was the major champion of these long-sought changes. AAKP testified before Congress last year asking for these needed changes for kidney patients and Congressman Stark pushed them through Congress. It would not have happened without him!

John Schall, MMP, is a Vice President with Jefferson Government Relations. He has more than 20 years experience with the Executive and Legislative branches of government. He is a public policy and communications professional with noted expertise in a wide range of policy fields.

This article originally appeared in the November 2008 issue of aakpRENALIFE.

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