Access to Better Choice in Dialysis Act of 2006 HR 5321

Discussions for Patients, Family, and Friends HD For Patients
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http://thomas.loc.gov/cgi-bin/query/z?c109:HR5321:

HR 5321 IH

109th CONGRESS

2d Session

H. R. 5321

To establish a pilot project to demonstrate the impact of payment for more frequent hemodialysis treatment under the Medicare Program.

IN THE HOUSE OF REPRESENTATIVES

May 9, 2006

Mr. BASS (for himself, Mr. MCDERMOTT, and Mr. SAM JOHNSON of Texas) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

A BILL

To establish a pilot project to demonstrate the impact of payment for more frequent hemodialysis treatment under the Medicare Program.

  Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

  This Act may be cited as the `Access to Better Choice in Dialysis Act of 2006'.

SEC. 2. MEDICARE PILOT PROJECT FOR PAYMENT FOR MORE FREQUENT HEMODIALYSIS TREATMENT.

  (a) In General- Not later than 6 months after the date of the enactment of this Act, the Secretary of Health and Human Services shall implement a 5-year pilot project to measure the impact of increasing the payment amount otherwise provided under section 1881(b) of the Social Security Act (42 U.S.C. 1395rr(b)), based upon the provision of hemodialysis treatment more frequently than 3 times per week.

  (b) Increased Payment Amount-

        (1) IN GENERAL- Under the pilot project, subject to paragraph (2), the increase in payment amount shall be, in the case of hemodialysis treatment provided--

              (A) for a 4th session in a week, 70 percent of the full composite rate;

              (B) for a 5th session in a week, 40 percent of the full composite rate;

              (C) for a 6th session in a week, 30 percent of the full composite rate;

              (D) for a 7th session in a week, 20 percent of the full composite rate; and

              (E) for any subsequent session in a week, no additional payment amount.

        (2) FUNDING LIMITATION- The pilot program shall be structured in a manner so that the total additional amounts paid under the program for hemodialysis treatment during--

              (A) its first year of operation does not exceed $15,000,000;

              (B) its second year of operation does not exceed $30,000,000;

              (C) its third year of operation does not exceed $50,000,000;

              (D) its fourth year of operation does not exceed $75,000,000; and

              (E) its fifth year of operation does not exceed $90,000,000.

        No expenditures shall be made for hemodialysis treatment under the pilot program after its fifth year of operation.

        (3) FUNDING FROM SMI TRUST FUND- Funds from the Federal Supplementary Medical Insurance Trust Fund under section 1841 of the Social Security Act (42 U.S.C. 1395t) shall be available, in advance of appropriations, to meet obligations arising from the pilot program under this section.

  (c) Data Collection and Analysis-

        (1) DATA COLLECTION- The Secretary shall provide for the collection of data to measure the clinical and financial impact of higher frequency hemodialysis treatments, including its impact on--

              (A) health status and on the utilization of, and expenditures for, other health care services, including for separately-billable drugs, such as erythropoietin (also known as Epogen), iron, and hospitalizations; and

              (B) patients' working status, resulting in--

                    (i) a reduction in Social Security Disability Insurance payments;

                    (ii) increased Federal and State income and employment tax payments; and

                    (iii) a reduction in Medicare payments due to increased coverage under employer group health plans.

        (2) REPORTS TO CONGRESS- The Secretary shall periodically submit to Congress reports on the pilot program under this section. The Secretary shall submit a final report to Congress and to the Medicare Payment Advisory Commission no later than 6 months after the completion of the program. Such final report shall include findings regarding the clinical and financial impact of more frequent hemodialysis treatment.

        (3) MEDPAC ANALYSIS- The Medicare Payment Advisory Commission shall evaluate the Secretary's findings in the final report under paragraph (2) and shall submit to Congress, no later than 6 months after the date of the Commission's receipt of such final report, and shall include in the report its analysis of the desirability of expanded medicare payment for more frequent hemodialysis treatment.

  (d) Definitions- In this section:

        (1) FULL COMPOSITE RATE- The term `full composite rate' means the rate determined under section 1881(b)(7) of the Social Security Act (42 U.S.C. 1395rr(b)(7)).

        (2) HEMODIALYSIS TREATMENT- The term `hemodialysis treatment' includes equivalent therapy requiring blood access, but does not include treatment administered on an emergency or acute basis.

        (3) SECRETARY- The term `Secretary' means the Secretary of Health and Human Services.

END
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Hi

While I support the plan and did email my house member. My concern is how do we get the centers to all have and adhear to the a set of rules or laws. unless a center has such a poor record where comsumers/patients are dying. The center seem to be able to get away with any thing. I know that if the comsumer/patients would stand up for their rights ,but if they feel it is a waste of time, what the use.

bobelanor :?:

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Hi y’all,

bobeleanor wrote:

My concern is how do we get the centers to all have and adhear to the a set of rules or laws. unless a center has such a poor record where comsumers/patients are dying. The center seem to be able to get away with any thing. I know that if the comsumer/patients would stand up for their rights ,but if they feel it is a waste of time, what the use.

Every center is required to follow the same laws, which are called the “Conditions for Coverage for ESRD Facilities.” Each state has Medicare inspectors who go around and periodically (sometimes pretty rarely) inspect each dialysis center–or who can be called in if there is a specific complaint. Each center is also required to post grievance procedures. One source of information for how this all works/fits together is the Patient Rights and Responsibilities module of Kidney School at http://www.kidneyschool.org.

Please keep in mind that this is Home Dialysis Central–discussions of in-center issues are best kept for another forum. We need to keep the topics here related to home.

Also, Bobeleanor, can you please repost your question about dialysis corporation costs as a new thread, or as a response in a different thread? The announcements weren’t really meant to be posted to. I should have locked them but didn’t. :roll: So, if you’ll repost it, I’ll delete it from where it was. Thanks!

4

Hi

I thought that hr5321 was more tx in center?

And yes I will repost my question. I justed wanted to check to see if the questions were out somewhere.
thanks

:smiley: bobeleanor

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Hi y’all,

I thought that hr5321 was more tx in center?

Actually, the bill itself doesn’t specify, so it can be either home or in-center.

In practical terms, trying to schedule short treatments 5 or 6 days a week is very difficult. It works best if you have pairs of people who can split the same shift. Otherwise, you end up with holes in the schedule, and the center loses money by not having the chair filled. Unfortunately, those pairs are very difficult to arrange, and even when they do work out, it often isn’t for long. So, it’s likely that a few, intrepid centers may try this in-center, but for the most part it’s likely to support more home dialysis.

6

Hi

I thought that the gove’t will not pay at all for home hemo?
That unless you the comsumer had a very good insurance company that was the only way home? Did anyone see the the NYT 5/14/06 on gove’t cutting funds for diabetes?
bobelanor :?:

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I thought that the gove’t will not pay at all for home hemo?

The government actually wants to encourage home dialysis. So, Medicare:
• Pays the same rate for home dialysis as they do for in-center, even though home therapies are cheaper to provide
• Gives Medicare benefits right away to home patients, but makes in-center patients wait 3 months

Many people have the misconception that Medicare pays for in-center but not home treatments, or that you have to buy your own dialysis machine if you do home hemo or CCPD. This is not true, and has never been true since 1973 when the Medicare ESRD Program was passed, offering coverage to people who are eligible.

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Dori writes:

The government actually wants to encourage home dialysis. So, Medicare:
• Pays the same rate for home dialysis as they do for in-center, even though home therapies are cheaper to provide
• Gives Medicare benefits right away to home patients, but makes in-center patients wait 3 months

Many people have the misconception that Medicare pays for in-center but not home treatments, or that you have to buy your own dialysis machine if you do home hemo or CCPD. This is not true, and has never been true since 1973 when the Medicare ESRD Program was passed, offering coverage to people who are eligible
.

If this is the case, what is the reason it has taken so long for home programs to become established?

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I think it has to be not beeing pro active in letting patients know about it…and of course technology…

Now that we have better dialysis technology suitable for home use then the opportunity us higher…

Its just a matter of spreading the word…

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Gus, I think there is more to this than just spreading the word. The word is out and has been out. Yes it needs to be spread more. If you want to get the word spread to the patients were going to have to find the key into opening centers up to the idea of offering homehemo and we need to ask our government reps to support the bills that support the financing so centers will have an incentive to offer the programs. Just walk into a center that offers home hemo and the subject is talked about open and freely and the word is spread by monthly news letters. the sight of the training rooms. Patient stories etc. etc. Now walk into a center that doesn’t offer home hemo and what do you hear…nothing. I’d like to know just how many centers offer home hemo. I’d guess not more than 10% of all dialysis centers offer home hemo. In NYS I’d bet it’s less than 5% easy.

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Hi

I wish someone could tell me why if dialysis company A offers home hemo in one center and says in that center that they want more people on home hemo. Then why is that not the the talk in the rest of company A other centers?

Thanks for the input.

bobeleanor :?:

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Even in large dialysis corporations, a lot of day-to-day decision making rests with the clinic administration and medical director. The key is getting the patients to ask for home dialysis options and to say they’ll leave clinics that don’t offer these options for other clinics that do and then follow through.

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Hi y’all,

Marty wrote:

I’d like to know just how many centers offer home hemo. I’d guess not more than 10% of all dialysis centers offer home hemo.

You can find this info out any time you like from the Home Dialysis Central Find a Center database at http://www.homedialysis.org/v1/centers/search.php.

Click only one box for one modality, and it will show you how many U.S. centers offer that treatment. There are about 4,700 dialysis centers in the U.S. right now:
• 1,527 (32.5%) offer CAPD
• 1,500 (31.9%) offer CCPD
• 343 (7.3%) offer conventional (3x/week) home hemo
• 99 (2%) offer daily home hemo
• 99 (2%) offer nocturnal home hemo

The interesting thing is, that growth has been greatest for nocturnal and daily home hemo since we started the site and built the database. Per the press release we just sent out yesterday because we have new DHHD and NHHD coverage maps, there was 106% growth in DHHD and 39% growth in NHHD programs in the U.S.–and I think we’re just seeing the beginning of the trend.

You can see the new maps at: http://www.homedialysis.org/v1/types/maps.shtml.

14

Hi

Even in large dialysis corporations, a lot of day-to-day decision making rests with the clinic administration and medical director. The key is getting the patients to ask for home dialysis options and to say they’ll leave clinics that don’t offer these options for other clinics that do and then follow through

Thanks Beth.
But how is someone in a center to know what choices are there if the center one is in won’t talk about it. When they do they make it sound very hard and that you could not handle the tx’s yourself? I said in another post that it up to the those that run the centers to give the people all the facts.
At what age do most people have to deal with dialysis? I know there are people of all age groups in dialysis.
thanks
bobeleanor :?:

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Reading the Bill I have some questions – when the Bill specifies 70% of the full composite rate is that saying:
[ul]1)Medicare will pay 70% for the forth treatment as opposed to the 80% it currently pays (in this case could providers bill secondaries for the 30%?).
or
2)Medicare allowed charge for a forth treatment is 70% of the current composite rate, meaning that Medicare would pay 80% of the forth treatment composite rate which would be 70% of current case mix adjusted rate (in this case could providers bill secondaries for more then the 20%?).[/ul]
It makes a difference since the total program expenditures are defined in the Bill. The per treatment expenditure determines in how many people can access this program.

If we assume that the current case mix adjusted composite rate for dialyzor A is $150 then under the first scenario a forth treatment would result in an additional Medicare program expenditure of $105 or a $5,460 per year. Given the first year expenditure cap 2,747 dialyzors could receive 4th treatments in the first year. Five treatments a week would result in a Medicare program expenditure of $165 per week or $8,580 per year allowing 1,748 dialyzors to receive 4th and 5th treatments in the first year; six treatments a week would result in a Medicare program expenditure of $210 per week or $10,920 per year allowing 1,373 dialyzors to receive 4th, 5th and 6th treatments in the first year.

Under the second scenario a forth treatment would be result in a Medicare program expenditure of $84 or a $4,368 per year allowing 3,434 dialyzors to receive 4th treatment in the first year. Five treatments a week would increase Medicare program expenditures $132 per week or $6,864 per year, per dialyzor allowing 2,185 dialyzors to receive 4th and 5th treatments in the first year; six treatments a week would increase Medicare program expenditures $168 per week or $8,736 per year, per dialyzor, allowing 1,717 people to receive 4th, 5th and 6th treatments in the first year.

Under both scenarios the number of dialyzors enrolled in the program would increase each year. By the fifth year the number of people able to have six treatments a week reimbursed would be somewhere between 8,238 or 10,302. This would represent an increase over current numbers by a factor of ten.

My other questions are in regard to how will access to the pilot program get allocated? I assume that a mix of schedules will be supported by the pilot – from four days a week to seven day a week schedules – is it open enrollment? How long of a commitment would a dialyzor have to make to access the pilot?

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Hi

So medicare will now only pay for three tx a week? If so why would someone go to the trouble for 3 tx a week at home? Outside of the babyk’s , the other machines run more, daily right? So medicare will not pay for them?

Thanks Bill and Dori and Beth.

bobeleanor :?:

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Medicare has never routinely paid for more treatments than 3 hemodialysis treatments a week. Additional treatment(s) require medical justification.

Some Medicare fiscal intermediaries (FIs) – the insurance companies that pay Medicare’s bills based on written policies – are more lenient than others. No one wants to jeopardize funding from those FIs that are lenient by complaining to other FIs that some providers in other areas get payment.

Some clinics choose to offer daily or nocturnal programs because they have enough patients that have commercial insurance that don’t set this arbitrary limit to offset the Medicare patients. In addition, those that offer daily and nocturnal dialysis report that their patients are healthier and take fewer medications making it less expensive to dialyze them over time once the clinic recoups the up-front costs of training and setting up the machine in the home.

Read FAQs about Medicare coverage of home dialysis:
http://www.homedialysis.org/v1/medicare/

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I wish all FIs were lenient and allowed more than three payments a week. I believe that section 1881(b)(7) of the Social Security Act (42 U.S.C. 1395rr(b)(7)) does not limit payments to three treatments a week, however, because the FI process is opaque it is not at all clear how the FIs make their coverage decisions. The FIs are another reason access to high dose dialysis depends on one’s zip code.

Medicare reimbursement policies should be the same no matter where you live. I’ve never been one to call in the lawyers but I do think that this is a situation that could be improved by a law suit – are there any examples of FIs being sued to expand coverage?

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Bill,

Medicare will always pay only 80% of Medicare allowable charges. As the average composit rate is $132, CMS pays 105.60, and insurance (if you have any) pays the remainder. On the fourth treatment, the rate would be 70% of $132, or $92.40, and Medicare would pay 80% of that, so the facility would receive 73.92. Seconday insurance will generally only pay for the 20% that Medicare does not pay.

This bill will give far greater benefit to home programs than it will incenter programs. In a home program, the additional revenue will help deferr the amoritization on the equipment, and spread out the labor costs (for nurse follow up, etc) over more treatments. The only additional costs that they incurr are supplies. In-Center programs will still have the same labor per treatment costs that they now have, and will lose money even on the 4th treatment as incenter labor costs plus supply costs will exceed the $73 payment.

Jim Curtis

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Jim wouldn’t you have to assume a continuation of the cost shift to private insurance primary dialyzors? By offering to pay even a minimum payment for forth treatments doesn’t 5321 offer the opportunity to bill private insurers forth charges? I think you’re most likely right in your calculaiton of the proposed rate but I didn’t think it was clear. Also I thought the average case mix aproved rate was close to $150 - maybe I’m thinking of post wage adjustment.

Also since the fixed cost of running a clinic is covered by the six day a week model couldn’t units offer seventh day treatments based on the marginal cost? Then you could reckon the marginal cost of a treatment, against the average revenue (average of payer mix). That should be a winner with 10% private primary.

It’s time we offered all dialyzors the option of a wellness weekend (4th treatment) as opposed to the deadly dialysis weekend. I think that’s doable under 5321 but a Bill that overtly addressed the issue would be better.