AAKP's infuriating support of cuts to the US dialysis program

[Bill Peckham]

http://www.aakp.org/userfiles/File/Rangle%20letter%20CHAMP%20Act%281%29.pdf

I'm sickened to read the above link that the American Association of
Kidney Patients is supporting the disastrous cut proposed in H.R. 3162
aka the CHAMP Bill. The shocking myopia of this transplant patient
guided organization is inexplicable and should be denounced by all
advocates for optimal dialysis outcomes.

Boo aakp. Boo. Hiss. If I was still a member I'd resign tomorrow.

Billp

[st789]

WTF!!!!   

[glitter]

Bill, will you please explain further why this is bad? I think I dont understand it very well.

[thegrammalady]

i don't get it either

[Zach]

Actually, the CHAMP Bill is a way better for patients than the so called, "The Kidney Care Quality and Education Act" -- S. 691 in the Senate and H.R. 1193.

AAKP should be applauded for not caving in to the financial "grants" that they receive from those making money off of people on dialysis.
 

[Bill Peckham]

The CHAMP Bill funds an expansion of the Children's Health Insurance Program (a good thing) but there is a requirement to pay for legislation through either taxes or cuts to other programs. The Bill pays for the expansion by cutting dialysis reimbursement. Sec. 637 of the Bill concerns development of ESRD bundling system and quality incentive payments. Beginning January 1, 2010, the Bill would create a bundled payment for dialysis and related drugs and services, with certain requirements to ensure appropriate anemia management. In so doing, total payments to dialysis providers would be limited to 96 percent of total estimated payments to dialysis providers if there were no bundled payment system. This means an dialysis program cut of 4% in 2010 while continuing the policy of having no yearly inflation adjustment to the dialysis payment rate.

So in addition to the yearly inflation cut there would be a forever decrease of 4% in the resources available for dialysis. We don't need fewer resources for dialysis we need more resources. We need the funding stability that would come from some sort of inflation update framework, we need universal access to higher doses of dialysis. Dialysis spending isn't the problem. Hospitalization spending is the problem. Dialysis is the solution.

[Bill Peckham]

Actually, the CHAMP Bill is a way better for patients than the so called, "The Kidney Care Quality and Education Act" -- S. 691 in the Senate and H.R. 1193.

AAKP should be applauded for not caving in to the financial "grants" that they receive from those making money off of people on dialysis.
 

Huh???  What part is better? Putting aside the 4% cut why is bundling EPO in with the composite rate in you interest? This Bill will accelerate industry consolidation. Industry consolidation is not in the interest of dialyzors.

[Zach]

This means an dialysis program cut of 4% in 2010 while continuing the policy of having no yearly inflation adjustment to the dialysis payment rate.

The dialysis industry has proven again and again, that it can't be trusted to do the right thing.  So there is a need for MedPac to evaluate each year the need for an increase--and that quality doesn't suffer.

There is a history of the industry ripping-off people on dialysis, and therefore cheating the American taxpayers. Sure, there are some notable exceptions.

As far as EPO, ever since it was approved for use, dialysis centers tried to take advantage of the reimbursement by Medicare.  Talk to Rep. Pete Stark if you need more info on the abuses.

So in addition to the yearly inflation cut there would be a forever decrease of 4% in the resources available for dialysis.

A decrease in the profit the industry makes from the reimbursement of medications such as EPO.
 

[Bill Peckham]

Zach the non-partisan Medicare Payment Advisory Committee (MedPAC) has recommended that Congress create an update framework for inflationary adjustments in Medicare's payment for ESRD care. These adjustments would account for normal increases in labor costs, some patient services and medication-related supplies.

Profit in the dialysis industry comes from private payors - this Bill would extend the private pay period from 30m months to 42 months. This Bill would increase Davita's and FMC's profits. Expanding the bundle will accelerate industry consolidation - it will make the provision of dialysis more profitable for Davita and FMC and squeeze all other providers.

EPO dosing is not a serious problem - the FDA just had an entire hearing on this very topic. Or did the FDA cave in to the financial "grants" that they receive from those making money off of people on dialysis?

[Zach]

EPO dosing is not a serious problem.

I'm not referring to hemoglobin levels, the abuses go well beyond that.

And profit also comes from Medicare reimbursement of injectable medications.  Let's get real.

Sorry Bill, but you need to speak to the legislators who, for over two decades, have been trying to solve all the different abuses of the dialysis industry.

[Bill Peckham]

I see this as at least three different issues.

   1. Taking money out of ESRD to fund other federal health needs. I think it is short sighted to sacrifice dialyzor health to fund other worthy needs.
   2. Decreasing the the over use of EPO. This is based on the JAMA article pointing to higher EPO use among the Large Dialysis Organizations (LDOs) than among the non-profit/Small Dialysis Organizations (SDOs). In addition there is a concern about the safety of EPO. I dispute the safety concerns as does the FDA but it is critical to understand that the apparent overuse data in the JAMA article is from 2004. Since 2004 Medicare has changed the dosing guidelines. In fact there is already data that EPO use is declining in response to the the changes Medicare instituted in November of 2006. If we're going to change EPO dosing guidelines let's do it in response to current data - the FDA looked at current data last week and did not find support for Congressman Stark's concern
   3. Expanding the dialysis bundle. I see a disconnect here. On the one hand people I talk to (Zach?) insist that they do not want more dialysis industry consolidation - the implication of this is that they are willing to forgo some of the economic efficiencies gained from consolidation to maintain the diversity of ownership. Yet these very same people advocate for expanding the dialysis bundle to include items that are impacted by economies of scale.

Let me try to explain #3 - it's the most confusing. The current composite rate is mostly not impacted by economies of scale. Wages, utilities, insurance costs are basically the same for an LDO as for a SDO (supplies are a relatively small part of the current bundle). The expanded bundle would likely include medications and lab tests, which are a very different type of expense and that difference matters. Because LDOs achieve significant savings, economies of scale, on the items in the expanded bundle the bundle rate could not impact various sized organizations equally. The size of the unit does not matter, what matters is the size of the unit's owner. A rural unit owned by a LDO could have a lower operating cost than a suburban unit owned by a SDO. A 4% cut is acceptable to the LDOs because they will reap a windfall from expanding the private payor period and because with further consolidation they will gain additional purchasing leverage.

I think it is the job of people who care about quality of care, we advocates of improving the provision of dialysis in the US to make sure our Representatives understand the impact of the changes they are considering. I would want every Member of Congress to know that If you're against consolidation and for non-profit healthcare delivery then understand that position means you are willing to loose some economy of scale (there is a trade off). However, I would point out that you could "have your cake and eat it too" if instead of capturing economies of scale because of provider size, you could instead use CMS's buying power. After all CMS has the biggest economy of scale potential. CMS could buy the Epo and sell it at their cost.

I would use any savings that resulted from CMS buying items in the expanded bundle to improve the ESRD program. We need to make the program better - healthier and safer.

[Bill Peckham]

EPO dosing is not a serious problem.

I'm not referring to hemoglobin levels, the abuses go well beyond that.

And profit also comes from Medicare reimbursement of injectable medications.  Let's get real.

Sorry Bill, but you need to speak to the legislators who, for over two decades, have been trying to solve all the different abuses of the dialysis industry.

Zach the testimony at Stark's hearing last month laid out the dynamics of Epo reimbursement. If you'd like the transcript I can send it to you. Stark himself said you can incentivize the over dosing of epo, or you can incetivize the under dosing. Bundling incentivizes under dosing - that will save money but are low hemoglobins in your interest? Reimbursing for just two treatments a week would save money too should we do that? Why not? How is that different than cutting Epo usage?

No comment on the FDA epo hearing last week?

When did we decide that progress in the provision of dialysis should be measured by economic efficency?

 

[Zach]

Bill, I'm not arguing about preventing consolidation.

I came to this post because of your attack of AAKP.  They do stand up to the "Caring Kidney" lobby, unfortunately, others don't.

I've posted on IHD many comments of the abuses of the dialysis industry:

http://ihatedialysis.com/forum/index.php?topic=1059.msg12525#msg12525

http://ihatedialysis.com/forum/index.php?topic=1059.msg12884#msg12884

http://ihatedialysis.com/forum/index.php?topic=1344.msg16190#msg16190

http://ihatedialysis.com/forum/index.php?topic=1344.msg16403#msg16403

CHAMP is by no means perfect, but its a better start than the "Kidney Quality Improvement Act" which was brought forth in part by the "Caring Kidney" lobby.

I stand by my words. Try not to mangle them too much.  Fini.
 
 

[stauffenberg]

The very idea of giving private, for-profit dialysis centers a fixed sum of money per treatment delivered has to work against the patient's interests, since the main way the dialysis provider can increase profit is by cutting corners on the service, to the detriment of the patient's health.  In contrast, if dialysis were a normal market, people could opt to buy higher quality service if the standard service became inadequate, but given the prohibitively high cost of dialysis for the average patient, demand for better service has no way to express itself as an influence on the supplier.  A better funding system would be to reward dialysis units financially for better health outcomes in their patients, rather than letting them increase profits by cutting corners within a fixed treatment reimbursement.  The social services of some countries have in recent years been made responsive to the needs of citizens using them by the device of a 'social charter,' which gives users of the service payments or refunds if the public service falls below a certain standard.  Dialysis could be organized the same way, with Kaiser and Davita having to pay the patients financial forfeits for rushing them out the chairs while they were still bleeding, having an unacceptably low hemoglobin level, taking off too much fluid and causing cramping because they would not extend treatment time, etc.

Instead, the U.S. government conspires with the dialysis suppliers against the patients by deliberately being as lax as humanly possible in its inspection of private diallysis providers for compliance with Medicare guidelines.  You could almost think that Marx was right when he spoke of apparently democratic governments as being in fact just agents for capitalists against their own people!

[Bill Peckham]

Bill, I'm not arguing about preventing consolidation.

I came to this post because of your attack of AAKP.

Look I've read your posts but I think there is a disconnect between your stated goals and the position you advocate. You link to the DeOreo breakdown of Medicare reimbursement. You acknowledge the history of reimbursement shifting from treatment to medication ... all good. But because epo is given intravenously you favor cutting the entire program. Nonsense.

Subq administration is problematic for a range of reason you do not acknowledge - from additional risks from inadvertent needle sticks through additional unreimbursed staff time to the fact that some diaylzors have no subcutaneous tissue. But this is a red herring.

The aakp should be condemned for advocating fewer resources for the provision of dialysis. Fewer resources will not improve care.

They do stand up to the "Caring Kidney" lobby, unfortunately, others don't.

I'm not sure why the Kidney Care Partners is on your shit list (yes that is me standing next to Alonzo on their home page) but it is misguided as is your opposition to HR1291/S635. If it all comes back to subcutaneous administration of epo say so but I would think you'd favor using subcutaneous saving to improve the program (though I doubt the savings would meet your expectations if outliers were accounted for.

[Bill Peckham]

http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=47609
From the above link it looks like the SCHIP legislation will not include cuts to the ESRD program. It will be hard for me to forget that the aakp thinks the provision of dialysis needs fewer resources and is now actually advocating for cuts to the system. I guess the one good thing that came out of this is that they showed their cards.

[bdpoe]

 
The AAKP is a big pharma and Provider driven organization pretending
to be there for the patients. I prefer the NKF instead.
After my first year, I dropped my AAKP subscription.
........bd

[Zach]

The AAKP is a big pharma and Provider driven organization pretending
to be there for the patients

That couldn't be furthest from the truth.

http://www.aakp.org/press/press-releases/2007/Support-CHAMP-Act/

[Bill Peckham]

I served on the aakp national board of directors. I know how decision are made by the aakp - they are not driven by their corporate underwriting which is extensive (checkout their 990 it's available on Guidestar after a free registration). The fact is the leadership of the organization does not understand the financing of dialysis. Kris has said herself that she is not a numbers person. She got herself on the bundling advisory panel for whatever reason and since then the aakp has supported bundling. Davita supports bundling. FMC supports bundling. Bundling and subq epo is the brier patch with the large for profit dialysis providers in the role of Brer Rabbit.

Their subq survey (the aakp subq survey touted by Executive Director Kris Robinson in front of Starks Committee in June) is fundamentally flawed - if you look at the actual numbers 3,600 surveys were sent out something like 750 of the respondents were actually on dialysis. They went looking to support a subq epo position and ginned up data to support it. Look if subq epo is such a slam dunk explain why Kaiser does not go to it nationally? Kaiser of South California requires subq epo administration yet their data has not lead to subq epo being adopted nationally.

The aakp is out of their depth and is being played. Look at the aakp statement at the FDA hearing. The hearing was about whether quality of life should be considered when weighing the cost/benefit of a particular HCT level - the FDA decided 33 to 36 made sense and quality of life is a valid consideration. The aakp's statement was about bundling and subq epo. They're not even paying attention to the discussion.

[Zach]

 

For Hurlock.

[Rerun]

 

[Bill Peckham]

Interesting - I had forgotten about this thread. I'm not sure why it was bumped? ... but it is interesting that here we are - the proposed bundle has been announced and I haven't heard word one about sub-q epo administration yet presumably once the bundle is implemented beginning in 2011 sub-q administration of epo will be the primary way of administering a dose.

I've read all of the nearly 600 comments to the proposed bundling rule and really only one commenter is flagging issues around Epo - Dennis Cotter who runs an EPO watch dog organization of sorts.