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  1. #1
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    Default Dialysis Industry May Expand as Study Sways Medicare

    Bloomberg

    November 24, 2010, 4:08 PM EST
    By Pat Wechsler

    Nov. 24 (Bloomberg) -- A study concluding kidney patients can improve their health by undergoing twice as many dialysis sessions may prompt the U.S. government to reconsider Medicare rules restricting payments to DaVita Inc. and other providers.

    Medicare, the health insurance program for senior citizens and the disabled, covers three sessions weekly unless more are shown to be medically necessary. An increase to six treatments may raise costs and require the dialysis industry to expand, said Alan Kliger, a clinical professor of medicine at Yale University in New Haven, Connecticut, and a study coauthor.

    About 400,000 Americans undergo dialysis, a procedure using chemicals to remove toxic waste from the bodies of patients whose kidneys aren’t up to the task. While more treatment would increase spending on dialysis in outpatient facilities, overall care costs may fall if patients remain healthier, said LeAnne Zumwalt, a vice president at Denver-based DaVita, the largest supplier of dialysis services.

    “It’s very good that we’re finally doing some studies that look at alternatives,” said Zumwalt, who handles public policy and regulatory issues, in a telephone interview.

    DaVita rose 59 cents to $72.94 at 4 p.m. in New York Stock Exchange composite trading.

    Peter T. Grauer, chairman of Bloomberg LP, the parent of Bloomberg News, is a DaVita director.

    Treatment Cost

    The cost of treating each patient with end-stage renal disease is about $75,000 to $100,000 a year, researchers said. Much of that expense comes from dialysis. The study was presented on Nov. 20 at the American Society of Nephrology meeting in Denver.

    The findings, which were also published by the New England Journal of Medicine, may provide ammunition for the patient advocates and doctors who have been lobbying Congress to allow Medicare to reimburse routinely for four treatments a week rather than three, said Arthur Henderson, a Nashville, Tennessee-based analyst at Jefferies & Co.

    “Getting reimbursement for four sessions has definitely been on the wish list,” Henderson said in a telephone interview. “The study might help those efforts, but there are immediate money pressures and not always immediate savings from these ideas.”

    Dialysis will cost Medicare about $240 a session next year, Zumwalt said. At least 85 percent of dialysis patients are on Medicare and get on average 145 sessions annually, she said.

    “More dialysis is better because when you’re on the Monday- Wednesday-Friday routine it’s hard to make it through the weekend,” said Lori Hartwell, a dialysis patient and founder of the Renal Support Network, in a telephone interview. The nonprofit advocacy organization is based in Glendale, California.

    Less Heart Damage

    For more than 40 years, patients suffering from advanced stages of kidney disease have received dialysis three times a week, for three to four hours a session, said Glenn Chertow, the study’s lead author and chief of nephrology at Stanford University School of Medicine, near Palo Alto, California.

    In the study of 245 patients, about half received more- frequent dialysis, for 2.5 hours a session. Researchers found six treatments a week resulted in less damage to patients’ left- ventricular heart muscles, Chertow said in a telephone interview. That should “translate into better heart function,” he said.

    While the trial was too small to conclude that more is better, it suggests that “our one-size-fits-all approach” needs to be reassessed, Chertow said.

    Reimbursement Changes

    It’s premature for Medicare, which is responsible for most spending on end-stage renal disease, to comment on the findings, said Ellen Griffith, a spokeswoman for the Baltimore-based Centers for Medicare and Medicaid Services.

    Reimbursement is changing on Jan. 1, when Medicare switches to “bundled” payments, involving a flat fee for the treatment that may include associated services such as lab tests.

    Expanding the number of Medicare-covered dialysis sessions may lead providers to add outpatient facilities and hire professionals to staff them, Yale’s Kliger said in a telephone interview.

    “Capacity would definitely be an issue,” said Mike Klein, chief executive officer of Renal Advantage Inc., a closely held dialysis company in Brentwood, Tennessee.

    Switching more patients to home dialysis may be one alternative, since the costs are less, with fewer facilities and personnel needed, he said in a telephone interview.

    Peritoneal Dialysis

    About 7 percent of home patients use a process called peritoneal dialysis, which relies on the abdominal lining to remove impurities with the help of a solution that is pumped into the belly area, according to the website of the Mayo Clinic, based in Rochester, Minnesota.

    Another 2 percent do hemodialysis, in which toxins are filtered from the bloodstream, said Jeffrey Burbank, president and CEO NxStage Medical Inc. in Lawrence, Massachusetts. The company makes a portable hemodialysis machine used in home dialysis.

    “There hasn’t been this quality of data before,” Burbank said. “I would hope this would have an influence.”

    --Editors: Jeffrey Tannenbaum, Adriel Bettelheim

    To contact the reporter on this story: Pat Wechsler in New York at pwechsler@bloomberg.net.

    To contact the editor responsible for this story: Reg Gale at rgale5@bloomberg.net.

    http://www.businessweek.com/news/201...-medicare.html
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  2. #2
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    Just have to ask, is there anything in all this to keep the treatment times from being cut too much?
    Proud member of DialysisEthics,
    responsible for:

    *2000 US Senate hearings

    *Doctors have to review charts before they are paid

    *2000 and 2003 Office of Inspector General (OIG) reports on the conditions in dialysis

    *2007 - Members of DialysisEthics worked for certification of hemodialysis
    technicians in Colorado - bill passed

    *1999 to present - nonviolent dismissed patients returned to their
    clinics or placed in other clinics or hospitals over the years

    www.dialysisethics2.org

  3. #3
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    There isn't anything more. I couldn't tell you what prevents units from cutting times today.
    [FONT=Times New Roman]
    [/FONT][FONT=Times New Roman]Dialysis from the sharp end of the needle
    tracking industry news and trends, in advocacy, reimbursement, politics and the provision of dialysis
    -------- -
    [/FONT][FONT=Times New Roman]-------- [/FONT]
    [FONT=Times New Roman]Home Hemodialysis: 2001 - Present [/FONT][FONT=Times New Roman]
    NxStage System One Cycler 2007 - Present
    [/FONT][FONT=Times New Roman]2days on/1day off, 30 Liters @ 250Qb ~ 8 hour per treatment FF28[/FONT][FONT=Times New Roman]
    Incenter Hemodialysis: 1990 - 2001
    [/FONT]

  4. #4
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    In Japan and Germany, one of the pay for performance targets for dialysis is that 85% of dialyzors must be getting at least 4 hours of treatment 3x/week (this would translate to 2 hours x 6 days a week). I think that would be an excellent goal worth working toward here, particularly in light of the DOPPS (Dialysis Outcomes & Practice Patterns Study) data among 22,000 or so dialyzors that found a 30% drop in the risk of death for folks who got at LEAST 4 hours of treatment. IMHO, there is no excuse for anyone to be getting less than this, regardless of body size. It is not possible to get too much dialysis (though it is possible to remove too much water and leave people feeling wretched--this is actually quite common).

  5. #5
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    Yeah, it did sound like we are only getting half the equation here: frequency, but not time. After watching this for ten years - and my friends and I dealing with the underbelly of this field of medicine, I hope you could understand how I would have trust issues.

    I like the idea of a 4 hour minimum, wondering if a minimum set by weight would be even better and possible?
    Proud member of DialysisEthics,
    responsible for:

    *2000 US Senate hearings

    *Doctors have to review charts before they are paid

    *2000 and 2003 Office of Inspector General (OIG) reports on the conditions in dialysis

    *2007 - Members of DialysisEthics worked for certification of hemodialysis
    technicians in Colorado - bill passed

    *1999 to present - nonviolent dismissed patients returned to their
    clinics or placed in other clinics or hospitals over the years

    www.dialysisethics2.org

  6. #6
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    Good question. Since there are data to support the notion of longer times, that might be easier to get through than a time-weight combination. For short daily HD, it looks as if a minimum of 15 hours/week is linked with the best survival, which makes sense, I think.

  7. #7
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    Quote Originally Posted by Dori Schatell View Post
    Good question. Since there are data to support the notion of longer times, that might be easier to get through than a time-weight combination.
    I see your point.

    By the way Bill, congratulations on the Atlantic-Propublica article! You are making an excellent spokesperson for dialyzors:
    http://www.propublica.org/topic/diagnosing-dialysis

    And it was good seeing both you and Dr. Blagg in the USA Today article:
    http://www.dialysisethics2.org/index...ath-rates.html
    Last edited by plugger_; December 1, 2010 at 07:52 AM.
    Proud member of DialysisEthics,
    responsible for:

    *2000 US Senate hearings

    *Doctors have to review charts before they are paid

    *2000 and 2003 Office of Inspector General (OIG) reports on the conditions in dialysis

    *2007 - Members of DialysisEthics worked for certification of hemodialysis
    technicians in Colorado - bill passed

    *1999 to present - nonviolent dismissed patients returned to their
    clinics or placed in other clinics or hospitals over the years

    www.dialysisethics2.org

  8. #8
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    CMS has published a proposed rule on the Quality Incentive Program (QIP) which proposes to reduce facility reimbursement up to 2% for facilities that do not meet certain targets starting in 2012 for:
    - Percent of Medicare patients with hemoglobin <10 mg/dL (weighting: 50% of the total facility score)
    - Percent of Medicare patients with hemoglobin >12 mg/dl (weighting: 25% of the total facility score)
    - Percent of Medicare patients with URR >65% (weighting: 25% of the total facility score)

    http://edocket.access.gpo.gov/2010/pdf/2010-18465.pdf

    It was proposed that non-Medicare patients and Medicare Advantage patients not be considered in the QIP calculation. Also proposed to be excluded from the QIP's URR calculation are home patients and patients who do >3x/week dialysis. All Medicare patients will be considered in the calculation of whether facilities have met hemoglobin targets.

    Does anyone think that the QIP as proposed could provide an incentive for facilities to encourage more patients to do home PD and HD and to provide >3x/week dialysis as a way to reduce any cut they may have faced for not meeting URR targets if 100% of their patients were on in-center standard 3x/week dialysis?

    I looked but could not find the final rule published in the Federal Register. If anyone else has seen the final rule, please post the link.
    Beth Witten MSW ACSW LSCSW
    Medical Education Institute, Inc.

  9. #9
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    The final rule has been due out any day since the end of October. Still waiting.

    People who don't use ESAs are excluded from the unit outcomes in the proposed rule ... the proposed rule will use the UMKECC approach to evaluating outcomes. I predict that beginning on 1/1/11 it will be discovered that EPO is contraindicated for many more patients than we ever had before.
    [FONT=Times New Roman]
    [/FONT][FONT=Times New Roman]Dialysis from the sharp end of the needle
    tracking industry news and trends, in advocacy, reimbursement, politics and the provision of dialysis
    -------- -
    [/FONT][FONT=Times New Roman]-------- [/FONT]
    [FONT=Times New Roman]Home Hemodialysis: 2001 - Present [/FONT][FONT=Times New Roman]
    NxStage System One Cycler 2007 - Present
    [/FONT][FONT=Times New Roman]2days on/1day off, 30 Liters @ 250Qb ~ 8 hour per treatment FF28[/FONT][FONT=Times New Roman]
    Incenter Hemodialysis: 1990 - 2001
    [/FONT]

  10. #10
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    Quote Originally Posted by Beth Witten MSW ACSW View Post
    It was proposed that non-Medicare patients and Medicare Advantage patients not be considered in the QIP calculation. Also proposed to be excluded from the QIP's URR calculation are home patients and patients who do >3x/week dialysis. All Medicare patients will be considered in the calculation of whether facilities have met hemoglobin targets.

    Does anyone think that the QIP as proposed could provide an incentive for facilities to encourage more patients to do home PD and HD and to provide >3x/week dialysis as a way to reduce any cut they may have faced for not meeting URR targets if 100% of their patients were on in-center standard 3x/week dialysis?
    What was the rationale for excluding Medicare Advantage patients? IMHO, in a gaming sense, the URR target might create an incentive for more PD or home HD, but since this is only 25% of the facilities' total score, and the entire P4P is only 2%, I suspect that reduced medications will end up being a bigger motivator. Since the direction is the same, though, I'm not sure how we'd ever be able to tell how much of a contribution URR made w/o a study...

    Quote Originally Posted by Bill Peckham
    I predict that beginning on 1/1/11 it will be discovered that EPO is contraindicated for many more patients than we ever had before.
    Why is that? And what impact do you think the new investigational drug that helps folks make their own EPO will have, if it turns out to be safe and hits the market? (http://www.medpagetoday.com/Nephrology/Anemia/23646.
    Last edited by Dori Schatell; December 1, 2010 at 09:04 PM.

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