As I’ve said before, I don’t know what CMS is going to do and don’t know that anyone does. I don’t even know if the people working on the bundle at CMS know exactly what the final product will be because when the proposed regulation is published there will be a public comment period and policies can be changed with well documented and justified comments.
I hope that CMS will consider the contents of the GAO report. I didn’t read the whole 118 page Report to Congress but did read the section of that report that contained information about the two proposed bundles. Former Sec. Leavitt understood that because of the way Medicare currently reimburses treatments and drugs, too many patients are doing in-center dialysis rather than PD and/or longer and/or more frequent home treatments. He also pointed out the concern expressed on this message board that the bundle needs to consider that patients may come and go from their facility during the month due to hospitalization and other reasons why service may be interrupted, as well as the fact that some patients may want or need to change facilities.
[I]The Secretary’s May 2003 report  pointed out that some critics have argued that the composite rate’s three times weekly payment structure regardless of dialysis modality has discouraged innovative treatment methods that could often lead to better clinical outcomes for patients and an enhanced quality of life. In recent years, ESRD facilities have relied heavily on separately billable drugs as a source of revenue growth. Some believe that this reliance on separately billable services has impeded the greater use of less costly PD and alternative treatment regimens such as nocturnal dialysis, home HD using compact portable dialysis machines, and shorter but more frequent dialysis sessions (1.5 to 2 hours).
An ESRD PPS combining composite rate and separately billable services furnished during a specified interval of time would provide the financing flexibility to use whatever forms of dialysis were in the patient’s best interests. Because of Medicare’s usual monthly billing cycle, an ESRD PPS based on monthly payments is a frequently mentioned approach. A unit of payment for an entire month is technically feasible. However, certain issues would need to be addressed such as hospitalization, the day of the month dialysis started, interruption of dialysis, and movement to other facilities. The alternative to a monthly unit of payment is the current system, which is per treatment.[/I]
As I’ve said before, now is the time to be gathering hard data on costs and outcomes and begin preparing a position paper that would include evidence supporting home dialysis, including reimbursement that encourages rather than discourages more frequent HOME treatments as well as a strategy for how to advocate with CMS and with other individuals and organizations to get them to support that position paper.
One of the things I take away from the GAO report is that all facilities haven’t provided data in the same way on their cost reports to CMS. When a facility provides data on costs for 3 treatments a week but provides 5-7, it doesn’t help the argument that it costs more to provide more treatments. Getting facilities to consistently provide data on all costs associated with the treatments they actually provide would be a good place to start and the time to start providing this is now.
Why not advocate with CMS to consult with providers of PD and more frequent treatments to develop explicit instructions for cost reports that would tell clinics to report ALL costs of home treatments, not just costs associated with the number of treatments Medicare covers and encourage CMS to allow facilities to use those instructions to file amended cost reports for prior years so data used by UM-KECC in calculating the costs of the bundle accurately reflects actual costs?