CMS is extending the availability of its recording of the Town Hall on the ESRD PPS until November 16th. You can access it at 1-800-642-1687 and when prompted entering the conference ID 33239635.
Hi y’all,
CMS is now extending the comment period until 5pm on DECEMBER 16. Please comment!
Hi y’all,
Please do comment–but please don’t waste the opportunity by:
– Just griping without offering a solution
– Asking CMS to not Bundle (they HAVE to do some type of bundle; Congress required it. The question is what goes IN the bundle)
–Parrotting others’ suggested comments without knowing what they mean (what is a “one size fits all” solution? How does it make sense, given the complex case-mix adjustment CMS is suggesting?). Use your own words, even if you want to make the same point. Say what the rule changes could mean for YOU and your life.
You can submit your comments online here–either type them in, or write them up in a Word document or PDF and attach them: http://www.regulations.gov/search/Regs/home.html#submitComment?R=0900006480a30c15
Hi y’all,
Here’s a link to a nice, short article by Denise Eilers and Kathe LeBeau from Renal Support Network about how the proposed bundle might affect patients: http://nephronline.com/article.asp?IndexID=286.
CMS has just released the new rule that includes the bundled payment for ESRD. It’s 900+ pages long, and the pdf is here: http://www.ofr.gov/OFRUpload/OFRData/2010-18466_PI.pdf. On a very quick read, it looks as if home dialysis training is included in the bundle (which is not what we’d hoped), but I’ll keep reading…
Still reading, but this looks promising:
Pages 181-182
Although we are continuing to include training payments in computing the ESRD PPS base rate, we agree with the commenters that we should treat training as an adjustment under the ESRD PPS. We believe the ESRD PPS base rate alone does not account for the staffing costs associated with one-on-oine focused home dialysis training treatments furnished by a registered nurse. Because the patient-focused training requires greater nursing resources than provided for non-training treatments, we feel that a separate training add-on adjustment is warranted.
Good start! Next quest: find out how much the training add-on is…
Ah: page 183. $33.44 per treatment–based on one hour of RN time. Interesting, since I believe most training sessions run more like 2-4 hours. Still, it’s an add-on, and it’s more than the $12 for PD/$20 for HD figure that was used previously.
Well, maybe–this figure is adjusted for the geographic wage index, so it could be as little as $20.03 or as much as $45.84.
$100 a week for home training is better than nothing
It looks pretty good to me: fewer adjusters, a list for labs, orals come in under a separate process after 2014
The focus on encouraging home treatments comes through loud and clear–it’s explicitly stated in several places. CMS also:
– Kept in the per-treatment payment
– Allows medical justification for more frequent HD treatments (so, training for, say, short daily HHD could mean $150 extra for training weeks, if training is done for 5 days). Medical justification criteria were not spelled out.
– Pays the same for PD and home HD as it does for in-center HD–to encourage more home treatments
The bundle does include lab tests, IV meds, and oral meds that have an IV version. It does NOT yet include “oral-only” meds, which are coming in 2014, leaving CMS time to solve some of the sticky problems Congress didn’t think through when they passed the bill (and CMS perhaps didn’t either, when they interpreted it). The case mix adjustment has been simplified, which is a huge plus.
Cross posted from DSEN
The Dialysis Payment Bundle - initial reaction
By Bill Peckham
The Centers for Medicare & Medicaid Services (CMS) issued the final rule creating a new bundled prospective payment system (PPS) for routine outpatient dialysis services. Skimming through the 900+ page PDF and the CMS Fact Sheet, I believe the new rule is an improvement on the initial proposal.
[ul]
[li]It is gratifying that there is a Home Dialysis training add on which CMS included in response to comments, particularly comments from dialyzors.
[/li][li]Oral-only drugs (binders) are not included initially but CMS will include them after 2014, following additional study.
[/li][li]Covered lab tests will be those on a list, rather than all blood tests ordered by the MCP physician.
[/li][li]There are a lot fewer case mix adjusters - CMS at this time will not use a patient’s sex or race/ethnicity to adjust payment.
[/li][/ul]
Those are important changes that improved the final rule.
Trying to understand what happened to the actual payment amount is a little trickier. On page 256 of the final rule, CMS writes:
To summarize, the final base rate per treatment with an outlier adjustment & budget-neutrality is calculated to be $229.63. This amount includes a 5.93% reduction from $251.60 to account for standardization to the projected CY 2011 current system payment per treatment, a 1% reduction to account for outlier payments, and a 2% reduction for the required 98% budget neutrality.
This as compared to the the initial proposal in September as laid out in NN&I by Tracy J. Mayne:
The predicted 2011 mean bundled payment was $261.58. This number was then reduced 21.73% to adjust for “anticipated positive effects” of the impact of the case mix adjusters, or ways in which the new payment system might pay more than the current system. It was then reduced by 1% as a cost offset to pay for anticipated outlier payments, and by another 2% to meet the congressional requirement for a 2% reduction in ESRD spend in 2011, to equal $198.64.
Under the initial proposal the mean bundled payment was reduced by 21.73% to accommodate all the case mix adjusters, under the final rule with far fewer adjusters the mean bundled payment is reduced by 5.93% to get to the base payment. While it appears that there is a $30 increase in the base payment, it really is just an effect of having fewer case mix adjusters. However, it does appear that the payment amount was increased a few dollars in the final rule.
The final rule uses $251.60 as a starting point. In September CMS used $261.58 but that $261.58 included the $12.48 CMS computed was necessary to pay for oral drugs. Given oral drugs are not in the final PPS I would expect CMS to use $249.10 as a starting point ($261.58 - $12.48). Therefor, I believe 251.60 represents a $2.50 increase per treatment over the September proposal.
I think my math is right but I might have missed a 1% adjuster somewhere that would have gotten the numbers to match. I’ll follow up once I’ve had more time to read through the complete rule.
I appreciate the amount of work CMS must have put in to review all the comments and fashion the final rule. I feel the effort I put towards understanding the proposal and commenting was worthwhile and led to a better PPS. I thank CMS for all their hard work and in particular their commitment to us on the sharp end of the needle.
I was pleased to see that the base amount is higher (it was too low!), but am still unclear about how oral-only meds will be handled until 2014. Did you figure that out?
It also really struck me that–though the purpose of the bundle was to hold down costs on IV meds–EPO in particular–there are several points where folks made comments re: concerns that behavior will change due to reimbursement, and CMS was shocked, shocked! at the idea that changing payment might alter clinician behavior. Seemed disingenuous (or naive) to me.
Orals will go in under a different process so they backed out the $12.48 they said would cover orals in the initial rule
After CMS studies the issue they’ll have to propose an amount and a process - I suppose there will be a comment period - to go into effect after 2014
Found it! Page 580:
(1) Part B drugs that were or would have been separately billable prior to January 1, 2011, will continue to be priced based on the most current ASP pricing plus 6 percent"…(4) Renal dialysis drugs and biologicals that prior to January 1, 2011 were or would have been separately covered under Part D, including ESRD-related oral-only drugs and biologicals for which we have delayed implementation until January 1, 2014, will be priced by NDC code based on the national average pricing data retrieved from the Medicare Prescription Drug Plan Finder."
I was just wondering if there was something in all this to encourage clinics to offer in-center slow nocturnal dialysis?
Good question, Plugger. I think the bundling in of IV meds is probably the best bet for in-center nocturnal. Since folks who get more dialysis need fewer meds, the clinics save money by giving better dialysis. But they won’t get the training payment unless people do in-center self-care for nocturnal (I’m not aware of any clinic that offers this, but that doesn’t mean it doesn’t happen). And, in-center nocturnal won’t make someone eligible for immediate (vs. 1st day of the 3rd full month Medicare) if they didn’t have Medicare before. IMHO, that 51% bump is going to be THE incentive for clinics to get uninsured folks or those who don’t have Medicare on PD ASAP.
So, someone, not otherwise eligible for Medicare, starts dialysis on PD which causes Medicare to be Primary from the start and then instead of taking the training rate they get four months of 1.51% payments.
Then, while they are using PD they get a fistula placed using their Medicare Primary Insurance so if the situation arises they can train for HHD.
That’s a good outcome.
There isn’t anything specific to encourage incenter nocturnal but like Dori said it is possible that including IV meds will push in that direction. I think when oral binders are included, after 2014, that will be an incentive since phos. control is much better with nocturnal.
[QUOTE=Bill Peckham;19997]So, someone, not otherwise eligible for Medicare, starts dialysis on PD which causes Medicare to be Primary from the start and then instead of taking the training rate they get four months of 1.51% payments.
Then, while they are using PD they get a fistula placed using their Medicare Primary Insurance so if the situation arises they can train for HHD.
That’s a good outcome.[/QUOTE]
Bingo. 
And, I agree that once binders are also included, it could create a further incentive for better treatments.
All right you math whizzes! I did have some questions and comments about all this.
That 51% bump, I’m assuming that is the increase going from the current composite rate (payment for treatment) to the new bundled payment rate. Is that correct?
As for people going on Peritoneal Dialysis, I’ve always been a bit leery of that after hearing all the horror stories about peritonitis. Much changed over the years?
I was just wondering what the 1.51% payments are?
And as a general comment I will say if [u]things were the way they should be[/u] we wouldn’t have to worry about people getting pushed into PD at the outset. However with all the healthcare reform and changes in dialysis maybe I’m going from steaming mad (which I was 10 years ago) to just cranky.
[QUOTE=plugger_;20010]That 51% bump, I’m assuming that is the increase going from the current composite rate (payment for treatment) to the new bundled payment rate. Is that correct?[/quote].
No. Each dialysis treatment used to be paid at a “composite” rate of about $150–with extra money for things like EPO. Now, there is a "bundled’ payment of about $229–with some adjustments for age, comorbidities, etc. But for NEW patients (who are eligible for Medicare), clinics will receive $229 + 51%, or about $345. That’s a big enough difference (x 48 treatments = $5,520) that clinics are likely to urge folks to start PD if they don’t have Medicare. That way, they will immediately become eligible for Medicare–so they pay less out of pocket (even the PD catheter can be backdated so Medicare pays for it), and the clinic will make much more money.
As for people going on Peritoneal Dialysis, I’ve always been a bit leery of that after hearing all the horror stories about peritonitis. Much changed over the years?
Peritonitis is about 100% preventable with good PD technique. Many clinics are now having people use mupirocin antibiotic ointment (Bactroban) on the catheter exit site to help prevent catheter infections. And, your chances of dying from an infection are higher with HD (access infections and sepsis) than they are if you get peritonitis. It’s painful, which is no fun–but that pain is an early warning system. Peritonitis can be treated with antibiotics at home. Sepsis requires a hospital stay.