John, is Medicare your primary insurance?
Yes, Medicare is primary for me.
John L
What were you told about following the usual in-center hemo diet when you’re on vacation doing 3x/week instead of your usual 2 hours a day x 6 days?
Every patient is different, but I don’t follow any special diet while on vacation either, I do watch my fluid intake while on vaca though.
John L
I’d love for any patient to be able to use any machine that any clinic offers and for clinics to offer multiple choices for patients. However, logistically, I don’t know how realistic this is. Staff need to know how every machine the clinic provides works so they can train people to use them and answer questions when patients call. I suspect clinics get better deals on cost as they order more machines for their patients. Bottom line…I’ve never seen any rule that requires a clinic to give a patient a choice of every machine, although this would seem to be the ethical thing to do.
Regarding traveling on dialysis, there are many sources of information about transient dialysis clinics. If the DaVita guest services person was discouraging, try one of the other sites where you can find clinics do in-center hemodialysis:
– The List (Dialysis and Transplantation) - www.eneph.com/thelist/index.asp
– Dialysis Facility Compare – www.medicare.gov/dialysis/home.asp
Beth,
What about OF the machines a unit offers. For example NKC offers the B Braun and the PHD. Isn’t it true that the unit must offer both choices to all patients (all patients, so far as insurance, not talking about compliance or ability, strictly talking insurance)? In other words nKC couldn’t offer Meidcare patients only the B Braun and three day a week dialysis while offering people with private insurance primary the PHD and daily treatments…right?
That was me…forgot to log in.
Hi Beth, Does that mean that people with private insurance have different choices then medicare patients in the same unit? Or do you mean that one machine might be perferable for one patient and therefore the decision would be based on what is best for the patient? Or do you mean the units are trying to make a profit off the machines they have bought and therefore will only let the people with private insurance use a certain machine to insure they get there return on the money they have put out? Say if that is the case, then they would not necessarily let someone on a new machine they are going to use if that person had medicare as a primary because there rate of reinbursment would be so much less? I really hope that is not the way things are.
Let me state up front that I have not seen any rule or regulation that requires a clinic to offer every patient every machine, but neither have I seen anything that says that they don’t have to do this. I have seen research that found income and health insurance affect care received in the U.S. and I would suspect this is true in other countries as well. For instance, people with Medicaid or no insurance are less likely to get kidney transplants. People with HMOs are more likely to be referred late to nephrologists. Patients with higher incomes live longer than people with the lowest incomes. I wish that people were treated equally, but as long as our healthcare system is the way that it is, I fear that this is only a dream.
I looked in the existing Conditions for Coverage for Suppliers of End-Stage Renal Disease Services (the regulation that governs dialysis clinics). It doesn’t addresses how a clinic should decide what machine to offer what home dialysis patient. Neither is there anything in the patient’s rights section about patients having a choice of home dialysis machines.
There are new draft Conditions for Coverage for End-Stage Renal Disease Facilities. This document says nothing about patient choice of machines for home dialysis. The preamble (before and not part of the regulation itself) says that treatment at home should be comparable to treatment in a facility and that support services for home patients should be comparable to those provided in a facility.
The proposed regulation is posted on the home page of the Home Dialysis Central website. In case you’d like to suggest more choice in home dialysis equipment, the deadline for comments on the proposed Conditions is 5 p.m. May 5. Instructions for comments are included in the proposed Conditions. It could be as much as 3 years before the regulation is final so until then, the existing Conditions are in effect. You can find the existing Conditions (21 pages) and the proposed Conditions (72 pages) under Professional Resources > Reimbursement at http://homedialysis.org/v1/resources/.
Beth this really concerns me, especially in light of the new case mix adjusted composite rate. There has been a gap between what private insurance will pay per treatment and what Medicare pays per treatment for a while now (as long as I’ve been paying attention). Since April there is now a wide range in what Medicare will pay (actually what Medicare will authorize as Medicare only pays 80%) from around $110 per treatment for someone of average size in their 60s to over $200 per treatment for someone in their 30s who has a large BMI. Then there are States like Florida where Medicaid pays even less than Medicare – I think Florida caps the per treatment reimbursement rate at $85. Which also means. I assume, that Medicaid in Florida pays none of the 20% not covered by Medicare.
I do not think providers should be able to limit the quality and quantity of dialysis based on a person’s insurance coverage. Providers get the opportunity to charge private insurers thousands and thousands of dollars per month (I’ve heard over $15,000 per month in some cases) because they are authorized Suppliers of End-Stage Renal Disease Services under Medicare’s rules. If the provider was not authorized to treat Medicare patients I doubt they would be able to attract private pay patients.
I’ve looked through the Conditions for Coverage for End-Stage Renal Disease Facilities and never thought about this issue. Providers should not be allowed to offer less treatment, shorter treatments or older equipment to Medicare patients. And among Medicare patients providers should not be able to limit access to high quality care bases on the various case mix adjusted rates. I’ve always thought of ESRD payments as a pooled resource – all funds, from all sources are pooled and then care is provided based on the person’s need and medical condition – paid for out of the pool. The idea of offering less treatment to the people on the low end of Medicare’s case mix adjustment and to Medicare patients in general is to me the biggest hole in the conditions of coverage and is a hole that must be filled.
I hope no one thinks I was condoning clinics, if any, that treat patients differently because of of their payment source. Since I’m a social worker and believe in equality for all, I don’t like to read about disparities in care based on someone’s ability (or inability) to pay. I don’t think we know that clinics are offering Medicare (or Medicaid) patients different machines or different treatments from what they offer patients with insurance that pays at a higher rate. Clinic staff I have talked with don’t do this.
I believe clinics that offer newer modalities such as daily and nocturnal dialysis believe they will come out OK even if they provide these treatments even if they’re not fully reimbursed for them because patients will be healthier and less expensive to care for otherwise. That’s been the point I make with social workers and other providers when I talk with them. Saying that, I wish that the U.S. had a better system of healthcare (which is actually a system of illness care).
Regarding the Medicare reimbursement of clinics under the composite rate. I found a Medicare transmittal (memo) that describes that the Medicare Modernization Act (MMA) mandated a 1.6% composite rate update and an 8.7% increase effective 1/1/05 because of the different way Medicare pays for drugs now. If you want to read what clinics were paid prior to case mix adjustment look at this:
http://www.cms.hhs.gov/manuals/pm_trans/R126OTN.pdf
The case mix adjustment was also mandated under MMA to keep Medicare payments “budget neutral.” Although I believe some patients cost more to care for and I trust those that came up with the case mix adjustment formula, I don’t think they had the key factors to consider in determining which factors to put into the adjustment. For instance, I know intuitively and because research has shown it that people that are very low functioning take more staff time and supplies because they have more needs during dialysis. Unfortunately there is no national source of data on patient functioning. We hope that this will change and are planning to comment on the Conditions for coverage asking for patient functional status to be part of the routine patient assessment. Here’s a training module with examples about how the new case mix adjustment works with different types of patients:
http://www.cms.hhs.gov/medlearn/finalchap3.pdf
By the way, I have heard that the Florida legislature is working on changing Medicaid reimbursement for dialysis from $85 to $110 per treatment. Florida is not the only state that caps reimbursement. Several states, including mine, pay little or nothing on top of what Medicare pays for Medicare/Medicaid patients. Here’s a copy of a story that discusses what’s happening in Florida:
http://www.orlandosentinel.com/news/orl-lockidney24042405apr24,1,5260048.story
Hi y’all,
I have never heard of an instance where clinics treated patients differently because of their payment sources. In fact, one of the things I’ve been impressed with in the dialysis community is the equality with which patients are treated, regardless of who is paying.
That said, we do know that about 93% of new patients in 2002 (the most recent year for data) began in-center hemo. We’ve made no secret that those of us who put together Home Dialysis Central would like to see that number MUCH smaller, and the numbers of patients who have access to and choose PD or home hemo much BIGGER.
So, we’re in favor of any efforts to raise awareness among patients that these treatments exist (a large study done a few years back found that fewer than 25% of patients had ever heard of PD or home hemo), and to make sure that access to home dialysis is increased–and fair.
I’m am not for socialized medicine, but I would like to see more non-profit centers open up. The quality of care is much better IMO (at least with the ones I have been a part of), because there is no need to worry about “the bottom line”. Non-profit centers are more likely to offer more options for care as well and not get locked into contracts with certain manufactures.
John L
Hi John,
I wouldn’t say that non-profit clinics “don’t have to worry about the bottom line.” A non-profit business is still a business; the difference is, instead of being in the interests of the owners or shareholders, a non-profit operates in the public interest, to serve a mission (the mission of the Medical Education Institute, for example, is "to help people with chronic disease learn to manage and improve their health–that’s why we do this website!). Like any other business, though, if they lose money, they will go under. Non-profits NEED to stay in the black, but “profits” are called “reserves,” and are set aside against future year shortfalls, rather than distributed to shareholders. Interestingly, a non-profit can own a for-profit, but no-one can own a non-profit.
As far as dialysis care being better in non-profits, there some studies have shown that, but some of them were flawed, so it’s hard to say. Some of the larger dialysis organizations are very data-driven and are keeping a close eye on many different aspects of quality care; something that might be hard for an independent or small non-profit clinic to duplicate. On the other hand, some of the best known and most well-respected clinics out there are non-profits. I think each clinic needs to be judged on its individual merits, and as you’ve probably seen, that can really depend on who the staff is at any given time.
As dialysis adminstrator (18yrs)of an independent and financially challenegd unit as well as a previous board member of the NRAA I would like to shed a little light on the Medicare coverage issues.
A provider should be billing for what it is providing. With DHHD it is six treatments per week. Regardless of the equipment used the costs for DHHD are significantly higher than traditional incenter treatment and providers should get reimbursed. If the payor denies any of the DHHD treatments the provider appeals the decision to the payor, including Medicare. In the appeal the provider must justify the need and benefit of the extra treatments.
If the payor ultimately does not approve and pay for all the treatments the provider should address the issue with the patient. For Medicare we are required to inform the beneficiary that the service is not covered and the patient is at risk for the charges. Many times the unit will bill the patient and ultimately write-off the balance. This is very provider specific.
There are many legal concerns about providing dialysis treeatments services for free as this can be construed as solicitation. And yes a provider legally can take the position that it will only provide services if the patient has adequate insurance/$ coverage for the services.
I would also like to add that there are many employer group health plans that do not pay well. Humana has always tried to negotiate less than Medicare payment rates. In our area the major plans pay the same or just slightly more than Medicare. Also major urban areas have to deal with a larger number of Medicaid patients.
It is complex but we all acknowledge that DHHD provides significant medical benefits and long-term $ savings to the payor with lowere morbidity and mortality. We all need to fight to get it adequately covered.
Hmmm. I don’t think Medicare is meant to be a ceiling, I think Medicare is meant to be a floor. In other words if a provider feels that to meet the needs of an individual they have to provide extra treatments then I think they are free to do so…I do not think that it would be considered solicitation. Otherwise what else is solicitation? Is having TVs solicitation? What about a three to one staff ratio? Or patient support groups? Is an educational patient conference solicitation? I believe Medicare, and the Conditions of Participation are meant to be floors that are intended to guarantee a certain minimum level of care. Many providers step up and provide care that exceeds the Medicare minimums and instead these providers meet community standards that are higher than Medicare’s.
To the second point – yes if someone has Medicare, Medicaid or private insurance then they are in the system (and without any insurance you are at the mercy of a system of chairity) but among that group of people withinsurance the care should be equivalent. Differences in length and frequency of treatment should be based on the individual as determined by the individual’s doctor. With the new case mixed composite rate there is a large spread in what is reimbursed even among people with the same insurance coverage – still while the amount reimbursed may vary the care available should only vary based on medical differences.
Sheri I would be very interested in any links you can provide that support your view particularly in regard to improved care being a form of solicitation.
Hi Sheri,
Thank you for clarifying this information. I know that there is a form called an Advance Beneficiary Notice that healthcare providers are supposed to give to patients if there is a possibility that Medicare will not cover a service. If the patient chooses to have the service anyway and Medicare does deny coverage, the healthcare provider can legally bill the patient. The challenge is how to medically justify more frequent/longer dialysis so fewer Medicare claims are denied.
Hi Bill,
Here is an Office of the Inspector General has issued a Special Advisory Bulletin that describes what is considered “inducement” and what the OIG has determined is allowed. Clinics are very concerned about violating this ruling because the penalties are steep – $10,000 for each “wrongful act.” This is the reason why clinics stopped helping patients with their health insurance premiums and why the American Kidney Fund started its Health Insurance Premium Program. I’ve heard of clinics that won’t provide patients with educational materials such as cookbooks that cost over $10 because the ruling prohibits “gifts” to patients of more than $10 per item or $50 per year. There are some exceptions.
I read Sherri’s post and the post with the law on it several days ago. Sherri’s post made sence, services provided, money expected. The law, if I understood it, made since also. The law is to protect the smaller business’ from the giant corportations to make an even playing field. Still after 4 days I was unsettled about Sherri’s post and the law. I know why now, who is watching out for the patient?
The Medicare surveyors are entrusted with the responsibility of watching out for the patients. Unfortunately CMS does not fund them well enough to survey clinics very frequently.
So far as the OIG interpretation, there are many (me included) that think that the OIG’s legal interpretation has harmed patients. Clinics are frightened to give patients educational materials if they have a value over $10. I just heard that a clinic that has a patient emergency fund (donated money) has told its social worker that financial help cannot exceed $10. I suspect $10 won’t pay for a taxi home in most cases and it certainly won’t go far in helping someone buy food or pay rent. One might say that patient assistance program funds could be donated to the American Kidney Fund or to the local NKF affiliate. However, an emergency is by definition something that requires help right away. Applications to national or even local agencies often take time to complete, file, and learn if it was approved or not.
By issuing this interpretation and leveling the playing field this way, it seems to me that the ruling of what is considered inducement does not really protect patients. Instead it keeps clinics from doing positive things for patients that some might choose to do. Instead of leveling the playing field in a positive way, this ruling is bringing clinics down to the lowest common denominator and making it possible for clinics to refuse to do one extra thing for patients if that thing has value.
In the last two and a half years I have been on dialysis I have spent that time dealing with my own feelings and watching my family deal with my illness. Even when I read the posts concerning politics I never paid much attention. I can see now the reason so many ask us to get involved politically. Our voice needs to be heard so furture laws can help make a level playing field for us.