Medical Care Should Be Reserved For The Non-Disabled

Rest of the article:

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60137-9/fulltext

[QUOTE=Unregistered;18281]Huh? But daily home hemo is already denied, and I thought the argument was that mortality and morbidities decreased with daily home hemo.

I thought that most of the people on this board wanted Medicare to expand coverage to daily home hemo. I’ve been hoping that eventually Medicare would cover the procedure so when the time comes for me I can go on it rather than in-center (I dread going back to in-center)[/QUOTE]

Where are you getting your faulty information? Medicare does cover daily home dialysis currently for most patients. We can’t be sure what the future holds when bundling takes affect because we’re not sure whether additional treatments due to medical justification will continue. But as data continues to be collected that proves home dialysis is a more effective modality and saves money when looking at the big picture we can be fairly confident payment will continue in some fashion.

Dori Schatell
Guest, daily home hemo is NOT denied to anyone on the basis of age. If it is denied, it is because Medicare will only pay for 3 treatments per week (for anyone), so the insurance plans can follow suit. So, that argument doesn’t hold up in this case.

Rich Berkowitz; Where are you getting your faulty information? Medicare does cover daily home dialysis currently for most patients. ]

Hmmmmm. I’d happily be wrong, but I though the Medicare paid for 3X per week, and any extra cost (for the supplies) comes from a non-medicare source.

I regard Medicare as dening coverage for dialy home hemo.

So my simple point was (to Bill) we already have a situation where Medicare denies care. Dori’s point is correct, in that is not given the Dr. Emanuel’s golden ages between 15 and 40, either. Buy if it is a scare resource (ie expensive) to whom would the intervention be given. I’m 60 and a little nervous.

BTW, how do people on slow nocturnal 6X / week pay for the xtra cost?..and how much is it? Thx

Rich

Hmmmm…well, i guess i inferred that from a lot of sources or maybe i haven’t been clear enough in my terminology…but i’m happy to be wrong.

First, when I said daily home hemo I meant nocturnal hemo done at home 6 nights a week.

Now I thought that the only thing Medicare covered was 3X week…anything in excess of 3X week was not covered. On this website there’s a statement “Medicare pays for 3 hemodialysis treatments a week. If you need more treatments, your doctor must justify them or Medicare will not pay for them”

So are you saying that the nocturnal HH (for 6 nights per week) is generally paid for by Medicare (or at 80% I guess).

So what is the current situation for nocturnal HH? Is it allowed for a few people? Or is the “medical justification” just a formality and everyone gets it?

And what does medical necessity mean? What type of people do NOT get a medical justitication.

Thanks for the info.

I’ve been wondering about the title of this thread. Did I miss something? Are you suggesting that medical care should be reserved for the non-disabled? If so, that would seem to imply that you support efforts to return people who are disabled and currently receiving SSI and SSDI to work, including people on dialysis. I totally agree with that on a variety of levels – improving physical functioning, emotional well-being, financial security. People who develop kidney failure who are working are more likely to choose a home dialysis treatment (PD or HHD) and home dialysis treatments improve the likelihood that people will feel well enough to work and have fewer interruptions in their work day to work. The only problem is that medium and small employers aren’t sure they want to keep dialysis patients on their payroll because the company that provides their health insurance may raise their premiums because of the high charges from dialysis providers.

This thread has gotten off on the same anti-reform message that NDXUFan12 has posted here and elsewhere. NDXUFan12, we got the message a long time ago. You’re against health/insurance reform for a variety of reasons, some of which are based on “facts” that aren’t facts. You have a right to your opinion. And others have a right to theirs. Just because you scream the loudest doesn’t mean you’re right.

QUOTING UNREGISTERED:
[I]"Hmmmm…well, i guess i inferred that from a lot of sources or maybe i haven’t been clear enough in my terminology…but i’m happy to be wrong.

First, when I said daily home hemo I meant nocturnal hemo done at home 6 nights a week.

Now I thought that the only thing Medicare covered was 3X week…anything in excess of 3X week was not covered. On this website there’s a statement “Medicare pays for 3 hemodialysis treatments a week. If you need more treatments, your doctor must justify them or Medicare will not pay for them”

So are you saying that the nocturnal HH (for 6 nights per week) is generally paid for by Medicare (or at 80% I guess).

So what is the current situation for nocturnal HH? Is it allowed for a few people? Or is the “medical justification” just a formality and everyone gets it?

And what does medical necessity mean? What type of people do NOT get a medical justitication.

Thanks for the info."[/I]

Medicare routinely pays for 3 treatments a week. Nearly from the start of dialysis (and even today if you look at the numbers of patients on each treatment), 3 treatments a week was the usual and customary dose of dialysis. If a patient has a medically justifiable reason why additional treatments are needed, the doctor can write a medical justification letter to the Medicare Administrative Contractor (MAC, the Medicare payer) that covers the geographic area where the provider is located to ask for approval/reimbursement for more treatments. Some reasons might include:
[ol]
[li]Fluid overload/LVH/heart falure [measures, intradialytic weight gain]
[/li][li]Hypertension [# meds, average BP, presence of LVH, CHF or other CV disease]
[/li][li]Metabolic bone disease {current PTH, binders, vitamin D dose, PO4, any bone complications]
[/li][li]Anemia control [EPO dose, current Hgb]
[/li][li]Quality of life [hardship of current regimin, what will patient do if he/she feels better]
[/li][/ol]

There are several choices for the patient and provider if the MAC does not approve extra treatments:.
[ol]
[li]The provider can prescribe and patient can do 3 times a week nocturnal which is better than 3 times a week conventional so far as removal of toxins, but doesn’t allow the patient to eat or drink as much as more frequent dialysis;
[/li][li]The provider can prescribe and the patient can do every other night dialysis which adds a little extra toxin removal to the 3x/week nocturnal and the MAC may or may not pay for the extra 1-2 treatments a month. If not, the provider can bill the patient’s commercial insurance if any for the 20% Medicare coinsurance for the treatments approved by Medicare and 100% for those treatments that are not Medicare covered;
[/li][li]The provider can prescribe and the patient can do 5-6 nights of dialysis for even better toxin removal and less restrictive fluid and diet limits. With Medical justification, Medicare may pay for more but probably not all of the treatments. The provider can bill the patient’s commercial insurance, if any, the Medicare coinsurance for Medicare covered treatments and 100% for the non-covered treatments.
[/li][/ol]

BTW, if the patient doesn’t have a commercial insurance, and the provider is considering billing the patient for the extra treatments, the provider must notify the patient that Medicare may not pay for all the treatments and have the patient sign an Advance Beneficiary Notice form that says to the provider the patient understands and wants the extra dialysis treatments anyway. I don’t know how many providers bill patients who do not have commercial insurance for extra treatments.

Before you knock Medicare for this, consider that commercial (private) insurance companies also have limits on what they will cover, what they will pay for those things they cover, and how long they will pay for healthcare needs of their subscribers. For example, you want to have a specific treatment because you have a brain tumor, but your insurance calls that procedure “experimental” after the fact, denies the claim and after your death, your spouse owes $170,000 in medical bills (I know the person this happened to). Or you want to do home dialysis and your insurance says that it only covers in-center HD (yes, this has happened to and only through extensive advocacy by MEI and others would the insurance company budge). Or you take 90 pills a month of a drug that the usual and customary dose is 30. Your doctor can present medical justification (studies, what’s been tried and failed, etc.) and your insurance company may (or may not) choose to allow payment for the extra 60 pills. In any of these cases (except the one you didn’t know your company was going to deny until after you got the service), if Medicare or your insurance company deny the benefit, you have a choice to refuse the treatment or take the treatment and pay for it.

At least when the government denies a service, it’s limiting the benefit to save taxpayers’ money. When insurance companies deny a service, people have paid premiums and the money that would have gone to pay for the benefit goes instead into someone’s pocket or to make the company profits look better to make Wall Street and investors happy.

[QUOTE=Unregistered;18303]Dori Schatell
So my simple point was (to Bill) we already have a situation where Medicare denies care. Dori’s point is correct, in that is not given the Dr. Emanuel’s golden ages between 15 and 40, either. Buy if it is a scare resource (ie expensive) to whom would the intervention be given. I’m 60 and a little nervous.[/QUOTE]

Dr. Ezekiel Emanuel has been misquoted and/or comments taken out of context. Read this article to find out the truth of his position.

Don’t be surprised if you’re asked whether you have an advance directive by your dialysis clinic. The new Conditions for Coverage require dialysis clinics to inform patients that they have the right to have an advance directive (AD) and to know if their dialysis clinic will honor their wishes (and they don’t get paid extra for asking like doctors would be paid for these discussions if this doesn’t get dropped from future legislation). Does this mean that the dialysis clinic wants to euthanize patients? Are you kidding me??? There’s too much money to be made off patients and their insurance/Medicare/Medicaid.

I have talked with many dialysis patients over the years about end of life planning to find out if they had an AD, to inform them about advance directives, and to make sure that the AD, if any, was on the chart to advise staff what patients who established an AD wanted or chose not to have if they couldn’t make their wishes known at any time in the future. Asking the question about ADs and end of life care is not equivalent to rationing care. In having this discussion, I learned which patients wanted no heroic means, which ones wanted all possible treatments, and anything in between. Asking the question allowed our staff and the patient’s doctor to honor patients’ wishes. As a reasonable person, I don’t understand how this section of the health reform bill could have been so twisted into citizens screaming that they don’t want euthasia. Crazy!

[QUOTE=Unregistered;18309]Rich

Hmmmm…well, i guess i inferred that from a lot of sources or maybe i haven’t been clear enough in my terminology…but i’m happy to be wrong.

First, when I said daily home hemo I meant nocturnal hemo done at home 6 nights a week.

Now I thought that the only thing Medicare covered was 3X week…anything in excess of 3X week was not covered. On this website there’s a statement “Medicare pays for 3 hemodialysis treatments a week. If you need more treatments, your doctor must justify them or Medicare will not pay for them”

So are you saying that the nocturnal HH (for 6 nights per week) is generally paid for by Medicare (or at 80% I guess).

So what is the current situation for nocturnal HH? Is it allowed for a few people? Or is the “medical justification” just a formality and everyone gets it?

And what does medical necessity mean? What type of people do NOT get a medical justitication.

Thanks for the info.[/QUOTE]

The reason the answer seems so confusing is that what happens is largely up to the provider (and their MAC (the contractor that actually pays on Medicare’s behalf)). For instance the Northwest Kidney Centers offers daily nocturnal while billing Medicare as it would were I dialyzing incenter.

To take myself as an example, I dialyzed three days a week incenter for 11 years, I now dialyze at home most nights - the billing has remained the same. Medicare get’s billed for 13 treatments a month.

Other providers offer daily nocturnal but expect and are typically paid for every treatment. Then there are providers that offer short daily in the same way - some bill and some do not.

So what is going on?

NxStage, from published reports, leases their service at a monthly that is less than 13 payments of 100% of Medicare’s allowed rate. In other words the cost of providing NxStage should cover the variable costs of service when billing 13 times a month. But remember too that the NxStage was originally immagined to use 20 liters of dialysate a treatment. On nocturnal I use 40 per treatment which increases the cost of providing NxStage beyond the original business model, large for profit providers may deicde that rather than risk incurring the added cost they would rather keep everyone on short daily - they have an easy out that the FDA’s marketing approval somehow limits their practice of medicne.

Fixed costs are another matter. The unreimbursed costs of training, monthly clinics, 24/7 support. Those costs are reimbursed slowly - the small excess when billing 13 times a month or more quickly when billing for every treatment.

So here is the question you need to answer. Should Medicare reimburse routinely for each treatment given at home, which would allow a device like the Aksys PHD to charge more which may have meant it could have stayed in business? Or should Medicare keep their reimbursement where it is, due to a historic accident, and force device makers to create something that pencils out at 13 payments a month?

[QUOTE=Beth Witten MSW ACSW;18343]Dr. Ezekiel Emanuel has been misquoted and/or comments taken out of context. Read this article to find out the truth of his position.

Don’t be surprised if you’re asked whether you have an advance directive by your dialysis clinic. The new Conditions for Coverage require dialysis clinics to inform patients that they have the right to have an advance directive (AD) and to know if their dialysis clinic will honor their wishes (and they don’t get paid extra for asking like doctors would be paid for these discussions if this doesn’t get dropped from future legislation). Does this mean that the dialysis clinic wants to euthanize patients? Are you kidding me??? There’s too much money to be made off patients and their insurance/Medicare/Medicaid.

I have talked with many dialysis patients over the years about end of life planning to find out if they had an AD, to inform them about advance directives, and to make sure that the AD, if any, was on the chart to advise staff what patients who established an AD wanted or chose not to have if they couldn’t make their wishes known at any time in the future. Asking the question about ADs and end of life care is not equivalent to rationing care. In having this discussion, I learned which patients wanted no heroic means, which ones wanted all possible treatments, and anything in between. Asking the question allowed our staff and the patient’s doctor to honor patients’ wishes. As a reasonable person, I don’t understand how this section of the health reform bill could have been so twisted into citizens screaming that they don’t want euthasia. Crazy![/QUOTE]

Dr. Emanuel or not this country, I believe, will see the rationing of care this year if the H1N1 virus is the least bit severe which will overwhelm our medical system’s capacity. Read Dr. Laird’s post on hospital triage rules … it isn’t going to be ability to pay that decides who gets care rather a judgment of docs and hospital administrators.

You are going to be on your own this Fall and your employer group health plan isn’t going to be worth more than your coverage card in your pocket.

It is my understanding that NxStage charges providers one set fee irregardless of how much therpay fluid a patient uses.

lots of info: Thx to Dori and Bill for specifics on Medicare re-imbursement on daily HH.

I for one am not going to let Dr. Zeke off the hook as easily as FacoCheck.org (and Jake Tapper) do.

First, the factcheck didn’t even mention the Lancet 2009 article. First, I’m not attacking Emunael for having the academic thoughtfulness to come up with a distribution scheme that he thinks is fairer to the society at large. But, clearly he says that most scare resource should be provide to those between 15 and 40…he made be “shocked” that people question that approach, but please.

Actually, Palin’s comments where generally used as a distraction to her main point, which was about rationing, not End of Life treatment

Here’s a nice article on the subject.

http://www.commentarymagazine.com/blogs/index.php/category/contentions/contentions?author_name=jpodhoretz

The problem is that government run health-care tends to create scarcity…taxation is never enough. (witness today’s Canadian Drs. saying that their healthsystem is imploding. (so calling Dr. Zeke may not be as much a fantasy as some think)

So will the US have shortages of medical interventions that qualify for Zeke’s model if we go single-payer. My hunch is yes, that’s what we’ll have in 10 / 20 years of a singlepayer plan.

What with the enormous deficits being run up, I for on can imagine that future government say, well, we can’t afford the extra cost of daily HH because we’re out of money. Or HD for those over 80.

And, Dori, I’m not sure that the “cost savings” of denied procedures will go to the taxpayer…they might go to fund the latest super-dooper weapons systems, or they might be absorbed into the vast government Leviathan. Or maybe they will just be used to provide marriage counseling.

Also, it your example of insurance not paying for experimental procedures (hopefully, the Dr. made that very clear)…one can see that a company would not be inclined to pay for something with uncertain value.

To re-frame that, think of the impact on premiums on a worker trying to make a living an covering a family via health insurance…his premiums would go up a lot if all manner of experimental treatments were tried……many of them may well fail, so where’s the justice there?