The big Medicare Modernization Act (MMA)from the 108th Congress required studies relating to the Medicare ESRD composite rate. Currently Medicare pays a composite rate that covers one dialysis treatment (the payment is suppose to cover the costs of providing the treatment – supplies and staff – about 80% of $140) and Medicare will allow 13 composite rate payments a month – basically three hemodialysis treatments a week. The MMA requires the Secretary of Health and Human Services (HHS), Michael O. Leavitt, to submit a report to Congress by October 1, 2005 that details the elements and features for the design and implementation of a bundled payment system for a range of services furnished by dialysis facilities. These elements would include the bundling of drugs, clinical laboratory tests and other items that are now separately billed by dialysis facilities. Also, the MMA requires the Secretary of HHS to conduct a three-year demonstration project beginning on January 1, 2006 relating to the use of a payment system for dialysis services that bundles the payment for drugs furnished to dialysis patients, including EPO, and clinical laboratory tests.
To accomplish this an advisory committee was formed, which has met three times; their meetings are open to the public and I am on an email distribution list that provides a report on what is discussed at the meetings. From what I have read of their deliberations their whole approach is flawed. Their approach will just perpetuate the status quo. What the advisory board discussed at their July 14th and 15th meetintg was to pay a monthly rate based on 13 treatments a month. They would include the big three drugs – EPO, iron and vitamin D – in a new bundled payment as well as the routine lab tests. How would that help patients? How does this address the 22% yearly mortality rate or reduce the 11 days a year the typical dialysis patient spends in the hospital?
I think the Congress’s intent was to allow providers more flexibility to achieve better patient outcomes. I can not see any benefit to patients in bundling the minimum level of care the current Medicare reimbursement system supports and this new approach will just further entrench the bare minimum level of care provided to the 90% of all patients who dialyze incenter. Congress has clearly indicated that home therapies should be encouraged and promoted yet the advisory committee is excluding PD from their demonstration and they are making no provision for home hemo let alone more frequent home hemo.
Significant savings are available to Medicare by improving the care given to dialysis patients. These savings could come from fewer hospitalizations – one fewer hospitalization a year would provide the funds needed for another treatment a week. However, this demonstration project does not look at that at all. The advisory board discussions revolve around rearranging the deck chairs on the Titanic - which by the way the average five year survival rate for a dialysis patient is the same as the average survival rate for a passenger on the Titanic, about 32%. The advisory board should be looking at ways to lower patient hospitalization and then use the money saved to give patients the option of doing away with dialysis “weekends”. At the very least the advisory board should be talking about patient satisfaction, expanding patient options and patient choice rather than simply changing the way Medicare pays for EPO. I think Medicare is out of sync with the intent of Congress and the needs of people on dialysis.
I think the bureaucrats at Medicare have already decided what the new payment scheme will include and the advisory board meetings, the demonstration project and all the rest are just hoops they’re jumping through to meet the legal requirements for change. It is too bad they are missing this opportunity to promote healthier treatment options, patient satisfaction and patient choice. It looks to me that it will take Congressional action to move from the current unacceptable status quo to a more progressive and humane system. Tweaking Medicare’s payment system should not be the end sought by this advisory board, changing the payment system should be the means to achieving better outcomes for all people on dialysis.