Has the Medicare ESRD program outlived its ussefullness?

Discussions for Patients, Family, and Friends HD For Patients
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Cross posted from billpeckham.com

Has the Medicare ESRD program outlived its usefulnesses?

                  The issue of the cost of dialysis to private insurance providers looks to be at the top of the agenda for 2008. [Renalweb](http://www.renalweb.com/) links to[Proposed Indiana Legislation for Dialysis Patient Rights](http://www.in.gov/legislative/bills/2008/HB/HB1323.1.html) Indiana House Bill 1323 and the [Kidney Care for Indiana web site](http://kidneycareindiana.com/) set up by Kidney Care Council. The bill passed out of committee this week and is expected to be voted on soon.

The language of the Bill seems to be a negotiating power grab by providers. It would seem that some for-profit providers have come to rely on charging private payers very high rates without having the negotiating strength to enforce their premium.
What I find troubling is the language adopted by the Bill’s proponents (their emphasis):Dialysis is the only chronic illness in the country that lets insurance companies off the hook. After 30 months, Medicare assumes responsibility for dialysis patients’ treatment and benefits, regardless of age. Prior to that, patients rely upon their private insurance plan to pay for their care.
Lets insurance companies off the hook? The Kidney Care Council seem to be advocating for an end to the Medicare ESRD program; is ending the Medicare ESRD program in the best interest of dialyzors as a group? Will be it in the best interest of dialyzors tomorrow?

2

Heh heh heh. Ideally, the providers would like to keep insurance companies “on the hook” as long as possible, because they can charge them much more than the Medicare rate. Given the large numbers of otherwise uninsured, however, particularly in a disease like ESRD that tends to cause permanent disability among working-age folks (largely due to the way it’s typically treated with in-center HD), I truly don’t believe it’s their intent to do away with the Medicare ESRD Program.

If we think having 47 million uninsured Americans in general is bad, imagine how awful it would look to go back to the days of the 1960s when folks died because they couldn’t get dialysis. Illegal aliens are in that position now, and it’s damned uncomfortable for those centers who must deny them care (or go out of business).

The real issue is that the Medicare rate for dialysis has not kept pace with the costs of care because dialysis is the only sector of Medicare that doesn’t get an annual increase for inflation. Unfortunately, IMHO, in the interests of practicality and cost (even more ironic given the current admin’s plan to give away $150 BILLION in additional deficit spending to shore up spending and hopefully rescue us from a recession), the Kidney Care Partners bill has given up on an annual update and is now advocating for a 3-year “trial” of an annual update. Well, duh, of course having more money would be better. I know that people aren’t supposed to watch laws or sausages being made, but I’m finding it really difficult to watch them pass up the straightforward equity argument in favor of pragmatics. <Sigh>

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I wish that legislators were more aware of the Medicare secondary payer provisions and would recognize that the Kidney Care Partners statement is not totally accurate. Even dialysis providers don’t know seem to understand the Medicare secondary payer rules inside and out or how to find the manuals that would answer their questions(http://www.cms.hhs.gov/manuals – look for Medicare Secondary Payer). I say this because no week goes by without me getting one or more questions related to who pays first that I either know the answer or can find it in the Medicare manual to share with the provider. Makes me wonder how accurate billing is and whether employer plans are being billed first or second as they should.

Other insurance companies that the country (read - federal government) “lets off the hook” are:
– health insurance companies that insure retirees who have company retiree coverage that by contract is always secondary to Medicare (Medicare supplement plans through former employers)
– health insurance companies that were already paying second to Medicare for someone who was disabled or elderly when that a patient developed ESRD
– health insurance companies that provide group health insurance coverage for disabled employees and dependents when the employer has 20 employees or less
– health insurance companies that provide group health insurance coverage to elderly workers or their dependents when the employer has 100 employees or less
– health insurance companies that sell individual health insurance plans that are not sponsored by an employer or union

What the KCP statement fails to mention is that in some ways insurance companies are more likely to be liable if someone is eligible for Medicare due to ESRD because employer group plans are liable for people with ESRD:
– no matter whether the employment status is current or former
– no matter how many employees the company has
– no matter whether the coverage is under the employee or spouse

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Just would note it is Kidney Care Coalition KCC v KCP

They also have a “patient rights advocacy” front in Kentucky

5

I guess I didn’t read closely enough. Ed Jones of Kidney Care Partners said this last year. It would be nice to have some clarification to other groups whose health plans don’t have to pay first.

I just found a new argument in support of keeping employer plans primary for an additional 12 months in the current online version of Nephrology News & Issues (see Extending the MSP)
http://www.nephronline.com/nephnews/index.php

[I]The Kidney Care Partners writes in defense of extending Medicare’s Secondary Payer status

By Edward R. Jones, MD, Chairman, Kidney Care Partners

As the chairman of Kidney Care Partners—a coalition of dialysis patients, professionals, care providers and manufacturers dedicated to working together to improve quality of care for individuals with kidney disease – and an advocate for the entire kidney community, I feel it is important to set the record straight with regard to extending the Medicare Secondary Payer (MSP) provision by 12 months.

The Medicare End Stage Renal Disease program is a 35-year-old program that serves over 400,000 Americans living with irreversible kidney failure – and one that I would add has not kept pace with patient and provider needs.

Extending Medicare’s secondary payer status for ESRD patients from 30 to 42 months is sound policy.

This 12-month extension will generate savings to the Medicare program which can then be used to educate people who have kidney disease and ensure their continued access to high quality care. And an additional year of responsibility for beneficiaries would only encourage private payers to adopt protocols that address patient wellness, prevent hospitalizations, and make dialysis safer and more efficient.

Kidney failure is, in fact, the only disease condition where private insurers can deny coverage. Even if patients want to remain in their private health insurance plan, they are required after 30 months of coverage to go onto Medicare. On the other hand, ESRD patients are eligible to drop private coverage and enroll in Medicare at any point after the third month of treatment, however many patients prefer their private coverage and would like the option to remain in private coverage beyond 30 months. As a result of the policy, kidney patients face coverage disruption, higher out-of-pocket costs, loss of integrated family coverage, and greater complexity. Dialysis patients should be afforded the same rights as others to choose how their care is financed.

And while improving quality of care and access for kidney failure patients, the MSP extension would have a negligible cost impact for private employers. It is estimated that between 5,000 and 10,0000 of the nearly 400,000 ESRD beneficiaries would remain privately insured from month 31 to month 42 if MSP were extended – and would be spread across hundreds of insurance plans. According to the most recent census data, approximately 200 million people are covered by private health insurance in the United States. Therefore, a 12-month extension of MSP would result in a 0.005-percent increase in the total population of privately-insured Americans. It is clear that the policy would have an insignificant impact, if any at all, on health insurance costs to employers.

Kidney patient advocacy organizations endorse the MSP extension as being in the best interest of patients, the Medicare program, taxpayers and the renal community. They say the MSP extension assures access and quality of life-sustaining care required by kidney patients:

The Renal Support Network, a patient organization of thousands of people with kidney disease, issued a letter to Senator Debbie Stabenow and the entire Senate Finance committee:

RSN supports the MSP Extension, citing its potential positive benefits to patients. These include extending patient choice and accessing the best quality of care possible, selecting the most comprehensive coverage and having the lowest out-of-pocket costs. It can also allow patients to maintain dependent family coverage and offer some patients access to disease management services that may improve outcomes and reduce overall costs.

In a letter sent to the Senate Finance Committee, the National Kidney Foundation (NKF) writes (click here to download a PDF of this letter):

“H.R. 3162, the Children’s Health and Medicare Protection Act (CHAMP), as passed by the House, contained enhanced benefits for kidney patients. NKF understands the need for an offset in the current Pay-Go environment. Therefore, we reiterate NKF’s longstanding decision to support extension of Medicare Secondary Payer, to 42 months, as proposed by the House, provided that the savings are dedicated to improvements to the Medicare ESRD program.”

The American Kidney Fund writes in a letter to the Senate Finance Committee (click here to download a PDF of this letter):

“We understand the difficult budgetary challenges you and your colleagues face and recognize that new spending must be offset by cuts in other areas. We support an additional 12 month extension of Medicare secondary payer (MSP) as a means to generate savings to help offset the costs of other improvements for patients in the ESRD program.”

An excerpt of a letter from DaVita Patient Citizens, one of the largest dialysis patient organization with over 20,000 members—pre-dialysis and dialysis patients as well as their family members—reads (click here to download a PDF of this letter):

“Besides restricting patients’ right to choose to keep their private insurance coverage longer, not extending the MSP period will prevent many of the needed reforms within the ESRD program. One of the most important steps is to provide those individuals at risk of kidney failure with education about the factors associated with kidney disease in the hopes of preventing them from reaching kidney failure. Consistently our members state that they were not aware of the risk factors that cause much of kidney disease—diabetes and hypertension. Prior knowledge could have reduced their risk of kidney failure and possibly dialysis, and the savings that MSP extension would achieve will help fund much-needed education and prevention programs.”

In a pay-as-you-go environment, a modest extension of MSP raises necessary revenues for critical reforms within the program. It is only designed to generate modest savings in Medicare to offset the cost of implementing key improvements to the program, such as coverage of educational sessions for pre-ESRD beneficiaries and quality payments, while also providing choice to patients.

The kidney community strongly supports reform in the ESRD program, which includes reforming the current MSP provision. Early identification, prevention and disease management are good for Medicare, taxpayers and patients who depend on quality kidney care.

*The KCP recently held an educational briefing about the Medicare ESRD program. To view the agenda, click here.

Nephronline.com - Powered by Nephrology News & issues - Renal News for the Kidney Care Community[/I]

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Why have the Medicare ESRD program at all?

Extending the logic of the KCP and KCC arguments wouldn’t they be just as true at the end of 42 months as they are at the end of 30 months?

Without the federal ESRD program people with stage five CKD would be in the same position as people with chronic pain or cancer or diabetes. There would be those with coverage and access to chronic disease management, those who spend down and qualify for Medicaid and then those with no coverage. We let people with cancer and diabetes without insurance manage on their own. Why have a special program for one disease? What is so special about people with CKD5?

People with CKD5 are special because dialysis works. Dialysis is like a switch, with regular dialysis people live, without it they die. If there was no federal ERSRD entitlement people dieing of “Bright’s Disease” ( to use the pre-Scribner word to refer to people dieing of kidney failure) without insurance would be treated in emergency rooms. Acute dialysis can be successfully preformed in a modern hospital, a hospital could keep people alive but is that the way our society, our neighbors want to proceed?

Every year about 100,000 people start dialysis. My guess is that of the 100,000 about 50,000 have Medicare due to age. Of the remaining 50,000 how would their coverage breakdown if there was not a federal ESRD entitlement? In 2006 the census bureau reported that 15.8 percent of all Americans did not have health insurance. I would assume that is higher among people with CKD4 transitioning to CKD5. Let’s say 20%. Is this the world we want? Every year 10,000 people dieing of Brights Disease?

On Average 22 people in every Congressional district, every year would be dieing of Brights Disease - young people mostly who for whatever reason do not have health insurance. When I transitioned from CKD4 to CKD5 in 1988 at age 25 I was not insured. I did not have a job that provided insurance until 1995, about 3.5 years after starting dialysis (I first tried a transplant). Where is KCP and KCC trying to take the ESRD program and the country?

Of course unaddressed in the KCC/KCP advocacy are charges of over $1,000,000 a year for dialysis and medications administered at dialysis units. By extending the private pay periods how many more dialyzors will run through lifetime coverage amounts? How many people in Indiana that are writing letters in support of out network charges will loose their jobs and their insurance after running up millions of dollars in charges? Is legislating a blank check for dialysis providers in the best interest of dialyzors? Some providers will be judicious and fill in the check for a reasonable amount but wouldn’t charging exorbitant amounts create competitive advantages?

The more that is charged the more that will be available after profits to pay technicians and recruit nurses. to keep up even the reasonable providers would have to charge more and more. Meanwhile the average reimbursement will continue to increase, increasing the gap between average reimbursement and Medicare reimbursement. As average reimbursement increases Medicare beneficiaries will receive even more services above what Medicare is paying for making it even more expensive to change the system.

Before I sign on to supporting this change I would like to know what the KCC/KCP vision is for CKD5 care in the United States. In the future they imagine, which insurers should be paying for dialysis and how much should they have to pay? And in this future what is the breakdown of coverage among the incident dialyzors?

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Hi Folks

Question, are all the people who do home dialysis when you get the EOB, if it from medicare or a insurance company still being charged the same as in center?I was under the thinking that if a person went home to do dialysis should there not be some saving?On my EOB’s the price is the same as if I was still in center. Can some one explain this?

thanks
Bob O’Brien

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Bob, home dialysis is cheaper to deliver than in-center care, at least once the equipment is paid for (may take a year or two). BUT…it’s a built-in incentive in Medicare that centers be paid the SAME amount for home as for in-center. Since they save money on it, the thought is that they would then encourage more folks to do it.

Because the training fee hasn’t increased over time (centers only get $20/day for one-on-one nursing care during training–how many nursing hours do you suppose that buys out in the real world?), this incentive hasn’t worked very well. Most people are never told that there are home options–you learned it on this site, if I recall–so they don’t ask for them, which is also a piece of the problem.

At any rate, that’s why you’re not seeing lower fees now that you’re home.

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Hi Folks

Dori

Who gets the money ,once your home? Is it the center or nxstage and Baxter?
Thanks
bob obrien

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The nurse who trained me went back and forth between my home training and other patients on the floor, just like nurses do on their normal workday. It’s not like they hire an extra nurse to do the home training. So why would they lose $$$ on training? They do have to be on 24 hour call, so I can see if they are called after work hrs, that is time that they must be paid for. I don’t know about other home patients, but I have never called my nurse after hrs. In our program we are told not to call unless it’s an emergency.

Also, it took forever for my clinic to start the home program. Now they tell me how happy they are that it’s making $$$ for them.

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[QUOTE=bobeleanor;15445]
Who gets the money ,once your home? Is it the center or nxstage and Baxter?[/QUOTE]

I assume they all get a piece of the pie. :slight_smile: NxStage and Baxter aren’t giving machines and supplies away for free–they get their fees from the center–and the centers get paid by Medicare and/or your private insurance for the things they do for you: training, support, monitoring your care, giving you medications, some lab tests, etc.

12

What you’re describing is a new, fledgling program. It’s not the best situation to have nurses splitting their time between caring for patients in the center and training–too easy to have your focus shift and miss something important.

Once a program is established and gets large enough, it will usually have dedicated nurses. It takes about 20 patients to support having one dedicated home nurse, and is better to have at least 2 so they can split up call. The rate of training depends on how many folks are trained at once (we advocate for small group training–2-4 dialyzors at a time). Some centers have looooong waiting lists, in part because they do 1-on-1 training, which takes a nurse many, many under-reimbursed hours to do. The problem with this is that folks can lose their jobs and health plans when they must wait months to get home.

13

Bob,
So far as who gets the money…It depends on whether the patient is on Method I (the dialysis clinic provides all services and supplies) or Method II (the patient gets supplies from a supply company and services from a dialysis clinic).

If Method I
The supplier bills the clinic for the equipment and supplies that go the the patient. The clinic pays the bill to the supplier and bills the patient’s commercial insurance or Medicare and all supplement plans, including Medicaid.

If Method II
The supplier sends the patient the supplies and bills the patient’s commercial insurance or Medicare and all supplement plans, including Medicaid (assuming it’s a contracted supplier). The dialysis clinic follows the patient 24/7 and sees the patient at clinic appointments and bills Medicare a set fee for that monthly coverage.

The doctor bills separately in either case and Medicare pays the doctor based on the number of visits/month for in-center patients or a set fee for home patients whether he/she sees them or not based on the same fee paid for 2-3 in-center visits/month.

Jane,
As Dori said, many clinics have a designated home training nurse who only staffs the home training department, trains every patient, handles all the calls related to home patients, and does nursing care during patients’ clinic visits. Typically only clinics with small home training programs require a nurse to do dual duty in the in-center clinic unless there is an emergency need. Once there are enough patients to justify it, it is more convenient to patients and the nurse to not have to work dual roles in the in-center clinic and the home training department. Every dialysis clinic I’ve worked in (3) has had a designated home training nurse.

14

Jane the main unreimbursed cost of training comes from doing the training five days a week and getting reimbursed for three days. I think this is a significant barrier to new home programs and would cost very little in DC terms to fix. I would guess that right now less than 2,000 people are training a year - if each one was supported with 8 additional treatments (21/month instead of 13/month) it would cost Medicare about $130 x 8 x 2,000 = $2,080,000/year . I think this would be the most impactful dollars the federal government could spend to improve the provision of dialysis in the US.

15

Hi Folks

So in either case is one way better for the consumer or the center? I keep stock of all my things and call both companies. they then send them to me… I had looked at both methods and did know if one was better?

Bob Obrien

[QUOTE=Beth Witten MSW ACSW;15449]Bob,
So far as who gets the money…It depends on whether the patient is on Method I (the dialysis clinic provides all services and supplies) or Method II (the patient gets supplies from a supply company and services from a dialysis clinic).

If Method I
The supplier bills the clinic for the equipment and supplies that go the the patient. The clinic pays the bill to the supplier and bills the patient’s commercial insurance or Medicare and all supplement plans, including Medicaid.

If Method II
The supplier sends the patient the supplies and bills the patient’s commercial insurance or Medicare and all supplement plans, including Medicaid (assuming it’s a contracted supplier). The dialysis clinic follows the patient 24/7 and sees the patient at clinic appointments and bills Medicare a set fee for that monthly coverage.

The doctor bills separately in either case and Medicare pays the doctor based on the number of visits/month for in-center patients or a set fee for home patients whether he/she sees them or not based on the same fee paid for 2-3 in-center visits/month.

Jane,
As Dori said, many clinics have a designated home training nurse who only staffs the home training department, trains every patient, handles all the calls related to home patients, and does nursing care during patients’ clinic visits. Typically only clinics with small home training programs require a nurse to do dual duty in the in-center clinic unless there is an emergency need. Once there are enough patients to justify it, it is more convenient to patients and the nurse to not have to work dual roles in the in-center clinic and the home training department. Every dialysis clinic I’ve worked in (3) has had a designated home training nurse.[/QUOTE]

16

Bob, we wouldn’t be here running this site if we didn’t believe that home is better for dialyzors, centers, and payors.

17

Bob,
Are you asking if Method I or II is better for patients? Few patients are on home dialysis under Method II compared to the number on Method I.

To be on Method II, you have to find a supplier willing to accept Method II. Most suppliers don’t accept Method II for hemodialysis because Method II reimbursement to the supplier ($1492) for HD is lower than what the clinic would be reimbursed under the composite rate.

CCPD uses a machine just like HHD, but HHD is reimbursed at the same rate under Method II as CAPD while CCPD is reimbursed at ~30% more ($1972 vs. $1490). I suspect PD equipment makers had to lobby hard to get the higher rate years ago.

A government report reviewed both Methods of reimbursement and advised CMS that Method II was too costly and that CMS should reduce the reimbursement under Method II for CCPD to the rate paid under Method I for CAPD.

Although our legislators believed that if patients negotiated with supply companies they could save money under Method II, in actuality patients paid more in coinsurance payments because of the higher reimbursement rate under Method II for CCPD anyway. It depends on the clinic’s composite rate (reimbursement under Method I) as to which Method is a better financial deal for patients.

So far as choice of Method and dialysis machines used, a patient choosing Method II must have a “home” clinic that trains him/her and provides follow-up care. A patient may want to use a specific machine but would find that difficult if the home training nurse at his/her home clinic did not know how to operate that machine. Another option that patients have used to get the machine they want is to call around to find out where it’s offered and training is provided.