By John A. Schall

On August 1, the U.S. House of Representatives passed H.R. 3162, the Children’s Health and Medicare Protection (CHAMP) Act of 2007. The CHAMP Act includes several important provisions relating to payment for end stage renal disease (ESRD) that were championed by AAKP. On June 26, Kris Robinson, AAKP’s Executive Director/CEO, testified before the House Ways and Means Health Subcommittee. This was a historic return for AAKP to the ornate congressional hearing room where Shep Glazer testified in 1971 while hooked up to a dialysis machine and receiving kidney dialysis. A year later, in 1972, Congress passed legislation to cover ESRD services under Medicare.

Much of what Robinson advocated in her testimony in June was included in the bill passed by the House of Representatives on August 1 – evidence that Congress recognizes AAKP’s role as the advocacy voice for all of the nation’s kidney patients.

The CHAMP Act includes some vital victories for kidney patients. Although it does not include everything we would have wanted, it does include many of the proposals AAKP directly recommended.

Highlights of the ESRD provisions in the CHAMP Act are:

Kidney Disease Education
AAKP strongly called for patient education services. Patient education is currently not covered by Medicare. But it only makes good sense to educate patients in the early stages of their chronic kidney disease (CKD). The earlier we can start educating patients regarding behavior, nutrition, and other matters, the fewer health problems will result later.

The CHAMP Act took AAKP’s suggestions to heart and created CKD demonstration projects. The bill also would provide Medicare coverage of kidney disease patient education services. The bill incorporates AAKP’s suggestion to widen patient education services beyond just dialysis centers and specifies that “the Secretary shall set standards for the content” of such education services “after consulting with physicians, other health professionals, health educators, accrediting organizations, kidney patient organizations, dialysis facilities, transplant centers, network organizations...and other knowledgeable persons.”

Training for Dialysis Technicians                                                                                                                                                                        The quality of dialysis services varies considerably in dialysis centers across the country. There is currently no national standard for training and certification of technicians in the centers. Some states, like Texas, have strong standards that must be met. Other states, like Florida, have none at all. AAKP would like to see standard training requirements that at least set a minimum for what training dialysis technicians should get.

The CHAMP Act would require training for patient care dialysis technicians, as called for by AAKP. The bill would require a technician to complete training and be “certified by a nationally recognized certification entity for dialysis technicians.”

Home Dialysis
AAKP has long championed making home hemodialysis a viable option for patients who want to choose it. But Medicare only covers three dialysis sessions per week, rather than the more frequent sessions associated with home dialysis.

The CHAMP Act tasks the Medicare Payment Advisory Commission (MedPAC) with a report, due March 1, 2009, on treatment modalities for patients with kidney failure. This is good news because MedPAC has long been on record recommending home dialysis. The bill asks MedPAC to make “recommendations for implementing incentives to encourage patients to elect to receive home dialysis services or other treatment modalities under the Medicare program.”

Dosing of ESAs
In her congressional testimony last June, Robinson said how important it was for kidney patients receiving ESAs such as epogen to receive appropriate dosages in line with FDA guidelines. Rep. Pete Stark (D-CA), who authored the CHAMP Act’s ESRD provisions, has voiced concerns about dialysis centers giving patients too much epogen – because the more epogen providers use, the more reimbursement they get from Medicare.

So in order to eliminate any unintended profit motive associated with epogen, the CHAMP Act would alter the way ESAs are reimbursed under Medicare. In 2008 and 2009, a “large dialysis facility” would be reimbursed at a set rate lower than the current payment. A “large dialysis facility” is defined as one that “owns or manages 300 or more such providers or facilities.” And then as of January 1, 2010, payment for ESAs will be included in the overall bundled composite rate for ESRD services. Importantly, payments in the bundle may be adjusted based on geography, pediatric services, low volume, rural areas and smaller facilities, as AAKP called for.

Quality Incentives
One of the most important victories for kidney patients in the CHAMP Act is the creation – for the first time – of quality incentive payments to providers. Robinson told Congress that not only is too much epogen a problem, but that underdosing of ESAs is a danger too. Many kidney patients remember the difficult times before ESAs were available, suffering the debilitating fatigue and adverse health affects associated with anemia. None of us want to return to those days and we do not want to scare patients away from being treated with these valuable life-enhancing medicines. We also do not want to create a perverse disincentive that causes providers to “skimp on” doses of ESAs because they would no longer be receiving separate reimbursement.

What we need is a Medicare policy that strives for a “Goldilocks” solution on ESAs: not too much, not too little, but “just right.” AAKP asked Congress to establish guidelines regarding the proper dosage of ESAs, and to link reimbursement to meeting those guidelines.

And that’s precisely what Congress is trying to do in the CHAMP Act. The quality measures address both overdosing and underdosing of ESAs and fistular access, as AAKP asked for. Providers will have to keep their patients at healthy hemocrit levels consistent with the FDA label for ESAs in order to receive the extra dollars. Quality improvement payments will equal one percent in 2008 and two percent in 2009 and 2010. This is a great start: AAKP has long supported linking quality of services to payment for those services.

That is why we are excited about many provisions of H.R. 3162. Congress clearly recognizes AAKP’s role as the voice for all kidney patients, and the House of Representatives acted on many of our recommendations – even in the face of a lot of political pressure. It still remains to be seen how many of the ESRD provisions remain in negotiations with the Senate and ultimately reach the President’s desk, but we are encouraged that AAKP’s voice has been heard loud and clear!

John A. Schall, MPP, is the vice president at Jefferson Government Relations.

This article originally appeared in the November 2007 issue of aakpRENALIFE