Has the new Bundle affected your Treatment/Care?

[Meinuk]

In January, the United States public health insurance program (Medicare) changed the way that it pays for dialysis treatments (changing from the 1983 composite rate to the 2011 bundled rate). This was many years in planning, and now, almost 91% of all dialysis units in the United States have agreed to participate in the Bundled payment system.  The first phase of changes have been made, and it affects almost everyone with CKD-5 in some way.

There are just under 400,000 people on dialysis in the United States.  One in seven people have some form of CKD.  Here at IHD, we have an amazing group of people who are active in their care and engaged in what is happening.   As an advocate, I have been watching from the sidelines for a while.  I've done some writing, lobbying, and a lot of reading. Now, I am in a position where I can be a small voice for change, I want to use my voice wisely, and for that, I need YOU to tell me what needs to be fixed, what needs to be advocated for and what works. 

It would really help if you would vote and share your comments/experiences on the bundle below now that some of the changes are in place.

(edited for typos and corrcted date of composite rate from 1988 to 1983)

[greg10]

Has anything changed with regard to CMS ruling on ESA and payment bundling?  The way I read it, it is business as usual.
If anything I feel that we are receiving more ESA (EPO) than we need.
We still pay $250 per month beyond what Medicare covers (no secondary insurance coverage) for home HD, which has so far been unaffected by bundling.
SUBJECT: Proposed Decision Memorandum for CAG # 00413N
Erythropoiesis Stimulating Agents (ESAs) for Treatment of Anemia in Adults with CKD Including Patients on Dialysis and Patients not on Dialysis
DATE: March 16, 2011
Given the totality of the currently available evidence, we propose that CMS not issue a national coverage determination at this time for Erythropoiesis Stimulating Agents (ESAs) for Treatment of Anemia in Adults with CKD Including Patients on Dialysis and Patients not on Dialysis (CAG-00413N). 
In order to maintain an open and transparent process, we are seeking comments on our proposal that no national coverage determination is appropriate at this time.  We will respond to public comments in a final decision memorandum, consistent with the spirit of §1862(l)(3).

[Bill Peckham]

In January, the United States public health insurance program (Medicare) changed the way that they pay for dialysis treatments (changing from the 1988 composite rate to the 2011 bundled rate). This was many years in planning, and now, almost 91% of all dialysis units in the United States have agreed to participate in the Bundled payment system, the first phase of changes have been made, and it affects almost everyone with CKD-5 in some way.

There are just under 400,000 people on dialysis in the United States.  1 in 7 people have some form of CKD.  Here at IHD, we have an amazing group of people who are active in their care and engaged in what is happening.   As an advocate, I have been watching from the sidelines for a while.  I've done some writing, lobbying, and a lot of reading. Now, I am in a position where I can be a small voice for change, I want to use my voice wisely, and for that, I need YOU to tell me what needs to be fixed, what needs to be advocated for, and what works. 

It would really help if you would vote and share your comments/experiences on the bundle below now that some the changes are in place.

91% didn't really "agree to participate", they opted to switch 100% to the new bundle as opposed to phasing in over 3 years. I think this is an interesting point though, that far more units went all in than CMS expected. CMS assumed that less than half the units would go all in; that most units would decide that this year getting paid 75% the old way and 25% the new way (then 50/50 in 2012, 25/75% in 2013) would be a good option. So you have to ask yourself What happened?

I think the reason providers went all in is that the bundle is structured in a way that will increase provider revenues. If the bundle does increase per beneficiary Part B expenditures (and thus provider revenues)  it will be because providers are providing more treatments. So one way the bundle might impact you is if you are being offered additional treatments and/or experiencing more intense intervention around skipping and/or any impacts on travel.

This travel issue is going to be important to track - problems here I think will portend larger systemic problems. I'd like to hear about people's experiences trying to arrange travel. If you need a largish dose of EPO to maintain your Hct. are units finding space for you to visit? If you do get in, do you receive your normal EPO dose? Has there been a change in your unit's willingness to support your travel?

[Meinuk]

Greg and Bill, you both bring up good points.  I am not dissecting the legislation, I am looking for the impacts, and my outcome is hopefully how we can work around them.  I am really looking for what is happening now.  Are there problems getting certain drugs?  Are you having to pay out of pocket?  Are you getting all of the supplies that you need?  Are you being asked to pay for things that you haven't had to pay for?  If so what?  How is it impacting you? 

Bill, impact on travel is a good question to ask.  I am just hoping that people will take time to answer.

[boclark54]

We were notified by our Insurance since the Emla cream my husband uses is for dialysis it will no longer be covered with new bundle and would have to be supplied by dialysis unit, since Davita doesn't give this out we now have to buy it ourselves. They will cover it if its not used for dialysis but we can't find any other reason to say its used for.

[tyefly]

I wish they would change the way we get our IV iron....  for home Dialysis....   I cant understand why we cant give ourselves iron at home when we need it... we give our selves heparin and epo  but we cant give our selves iron...  we have to go into the clinic and cannulate ourselves to get the iron....  we are already doing D six days a week at home with six days of cannulations... and when we need iron we have to go to the clinic and cannulate ourselves again that day to get iron... the clinic protocol is to have you come in for one day for 4 to 5 weeks to get the iron....  I am doing D at home for a reason .... I dont want to come to the clinic every week... anyway... I think that we could give ourselves IV iron if we are responsible to do D at home...

[Marina]

Has anything changed with regard to CMS ruling on ESA and payment bundling?  The way I read it, it is business as usual.
If anything I feel that we are receiving more ESA (EPO) than we need.
We still pay $250 per month beyond what Medicare covers (no secondary insurance coverage) for home HD, which has so far been unaffected by bundling.
SUBJECT: Proposed Decision Memorandum for CAG # 00413N
Erythropoiesis Stimulating Agents (ESAs) for Treatment of Anemia in Adults with CKD Including Patients on Dialysis and Patients not on Dialysis
DATE: March 16, 2011
Given the totality of the currently available evidence, we propose that CMS not issue a national coverage determination at this time for Erythropoiesis Stimulating Agents (ESAs) for Treatment of Anemia in Adults with CKD Including Patients on Dialysis and Patients not on Dialysis (CAG-00413N). 
In order to maintain an open and transparent process, we are seeking comments on our proposal that no national coverage determination is appropriate at this time.  We will respond to public comments in a final decision memorandum, consistent with the spirit of §1862(l)(3).

Greg, 
here's  what I  found  on  Dialysis Patient  Citizens:

   
http://www.dialysispatients.org/dpc-enewsletter-april-2011
 CMS Proposes to Maintain Current Reimbursement Policy for Anemia Fighting Drugs
 On March 16, 2011, in response to a public request, the Centers for Medicare and Medicaid Services (CMS) reviewed its coverage policy for ESA (erythropoietin stimulating agents, also known as EPO) use in patients with Chronic Kidney Disease (CKD), including those on dialysis.  CMS stated they are proposing not to issue a National Coverage Determination (NCD) at this time. This means that for now, CMS is proposing to keep existing reimbursement policy in place. This is a positive move for kidney patients because it places no additional barriers for patients and physicians to make decisions about the treatment of anemia. 

DPC (Dilaysis  patient Citizens) was concerned CMS would develop a policy to further restrict kidney patients’ access to ESAs to treat their anemia. While we believe all patients should be informed of the risks and benefits of ESA use, it is important that payment policies do not interfere with patients and physicians making decisions about the best course of treatment. We also strongly believe that when federal agencies are reviewing the evidence on benefits and risks of any medication that they should also look at patient self-reported quality of life.
 

[Zach]

Greg, 
here's  what I  found  on  Dialysis Ratient  Citizens:[/size][/color][/b]

http://www.dialysispatients.org/dpc-enewsletter-april-2011
 CMS Proposes to Maintain Current Reimbursement Policy for Anemia Fighting Drugs
 On March 16, 2011, in response to a public request, the Centers for Medicare and Medicaid Services (CMS) reviewed its coverage policy for ESA (erythropoietin stimulating agents, also known as EPO) use in patients with Chronic Kidney Disease (CKD), including those on dialysis.  CMS stated they are proposing not to issue a National Coverage Determination (NCD) at this time. This means that for now, CMS is proposing to keep existing reimbursement policy in place. This is a positive move for kidney patients because it places no additional barriers for patients and physicians to make decisions about the treatment of anemia. 

DPC (Dilaysis  patient Citizens) was concerned CMS would develop a policy to further restrict kidney patients’ access to ESAs to treat their anemia. While we believe all patients should be informed of the risks and benefits of ESA use, it is important that payment policies do not interfere with patients and physicians making decisions about the best course of treatment. We also strongly believe that when federal agencies are reviewing the evidence on benefits and risks of any medication that they should also look at patient self-reported quality of life.

Just remember that Dialysis Patient Citizens is a front for DaVita, so whatever they claim is suspect at best.

[PatDowns]

You do realize that DPC is a part of DaVita.  And, the government has  been after DaVita for over prescribing EPO to increase reimbursement.

Has anything changed with regard to CMS ruling on ESA and payment bundling?  The way I read it, it is business as usual.
If anything I feel that we are receiving more ESA (EPO) than we need.
We still pay $250 per month beyond what Medicare covers (no secondary insurance coverage) for home HD, which has so far been unaffected by bundling.
SUBJECT: Proposed Decision Memorandum for CAG # 00413N
Erythropoiesis Stimulating Agents (ESAs) for Treatment of Anemia in Adults with CKD Including Patients on Dialysis and Patients not on Dialysis
DATE: March 16, 2011
Given the totality of the currently available evidence, we propose that CMS not issue a national coverage determination at this time for Erythropoiesis Stimulating Agents (ESAs) for Treatment of Anemia in Adults with CKD Including Patients on Dialysis and Patients not on Dialysis (CAG-00413N). 
In order to maintain an open and transparent process, we are seeking comments on our proposal that no national coverage determination is appropriate at this time.  We will respond to public comments in a final decision memorandum, consistent with the spirit of §1862(l)(3).

Greg, 
here's  what I  found  on  Dialysis Ratient  Citizens:

   
http://www.dialysispatients.org/dpc-enewsletter-april-2011
 CMS Proposes to Maintain Current Reimbursement Policy for Anemia Fighting Drugs
 On March 16, 2011, in response to a public request, the Centers for Medicare and Medicaid Services (CMS) reviewed its coverage policy for ESA (erythropoietin stimulating agents, also known as EPO) use in patients with Chronic Kidney Disease (CKD), including those on dialysis.  CMS stated they are proposing not to issue a National Coverage Determination (NCD) at this time. This means that for now, CMS is proposing to keep existing reimbursement policy in place. This is a positive move for kidney patients because it places no additional barriers for patients and physicians to make decisions about the treatment of anemia. 

DPC (Dilaysis  patient Citizens) was concerned CMS would develop a policy to further restrict kidney patients’ access to ESAs to treat their anemia. While we believe all patients should be informed of the risks and benefits of ESA use, it is important that payment policies do not interfere with patients and physicians making decisions about the best course of treatment. We also strongly believe that when federal agencies are reviewing the evidence on benefits and risks of any medication that they should also look at patient self-reported quality of life.
 

[Bill Peckham]

The call for public comments that that DPC was commenting on isn't exactly part of the bundle but if there was a change it would mean that the value of the bundle would have to be adjusted under a separate process. CMS was asking for comments on the treatment goals of ESA therapy among people using dialysis and predialysis (stage 4 CKD). Right now for people using dialysis the goal is a Hgb between 10 and 12; a national coverage decision by Medicare could change the target. DPC is saying don't change the targets which I think is a consensus position in the community.

Here is the complete public comment from the Renal Physician's Association
http://www.cms.gov/medicare-coverage-database/staticpages/public-comment.aspx?commentID=21292&ReportType=nca

which I would say is as good a surrogate as any for the community's conventional wisdom.

It isn't clear how the financial incentives work out under in the post bundle environment. The current bundled rate is based on the idea that CMS is paying the provider to achieve a Hgb between 10 and 12. If you assume the payment stays the same it is in the financial interest of the provider to lower the target (a target of 8 to 10 is cheaper to maintain than a target 10 to 12). Historically DPC has taken pro EPO, pro higher target Hgb policy positions in the name of patient quality of life. Prior to January 2011 the pro higher Hgb position happened to coincide with the business incentives of providers but now, in a post bundle world things have changed. FOr instance, it isn't in the business interests of DaVita to have a medical justification for a Hgb target between 12 and 13.5 because the bundle does not include a mechinism to be paid more but allowing a higher Hgb had been DPC's position. Is it still DPC's position? Maybe it is. If it is that would show some organizational independence.

[McJetter]

My husband is on hemodialysis at a Fresenius Unit.  He just called to tell me he is now being billed $27.00 a month out of pocket for the doctor that sees him in the unit.   He has Medicare as primary (Anthem has already paid primary for 30 months) and now our Anthem (my insurance) is secondary.  So, with Medicare and Anthem as secondary we have an additional $27.00 out of pocket each month.  From what I understand from my husband, the doctor stop says how are you doing, if okay, he walks on, and if you have an issue, he tells you to schedule a visit with your Nephrologist.  Actually getting an appt with his Nephrologist has been increasingly difficult also.  The billing person at Fresenius told him the additional charge was due to a change in his insurance, she didn't mention the new "bundled" payment system to him.   

[Grumpy-1]

I now have Medicare as primary and now our Anthem (my insurance) is secondary.  I have to pay about $300 to Medicare every 3 months and the normal insurance premiums from work are the only costs I currently have.  My Nephs are the ones I see at the clinic and so they charge the insurance and Medicare.  I don't have any co-payments at ANY doctor appointments I have.   Grumpy

[Rerun]

We  no longer get lidocaine and have to bring our own.  They say it is a shortage.

The big difference I noticed is my explanation of benefits from my secondary insurance submitted charges went up 10K a month.  Now the submitted charges from DaVita is 55K.  A MONTH!

They only get $2,500 and they KNOW that is all they would get. 

So make them (DaVita) tell the damn truth on what it costs.  NOT what they WANT.

If they were losing THAT much money the CEO would not be making 29 million a year.   Off sick people.

Truth in healing......  That would be a good title.

[Tío Riñon]

Medicare just became primary for me last month and BCBS is now secondary.  I'm more than a little annoyed because I'm having to pay about $300/quarter to Medicare.  I normally don't have to pay any premiums because my health insurance is fully covered as a benefit of my position.  Now I'm having to budget for this new expense due to the 30 months of coverage rule.

A surprising benefit of the bundle, as reported to me by my dietitian, is that I no longer have to purchase Calcitriol because it is part of the bundle.  Is anyone aware of other drug benefits that will be included in these bundles?  She also said that hopefully all binders and Sensipar will be part of the bundle starting in 2016.

[Shaks24]

Yes. I used to buy it from the pharmacy. The last two orders have come from Fresenius as part of the bundle. They send it to me by mail.

[Shaks24]

May have to retract my comment above. Just got a bill of 27.44 per month for 2 months of Calcitriol .25. Whats strange is that my PD Nurse told me it was part of the bundle. Does anyone have a link to information showing it is part of the bundle? I am not paying it until I talk to my nurse and social worker. The bill came from Fresenius Rx.

[Shaks24]

Found a good link by Davita. Pretty comprehensive information on the bundle.  http://www.kidneycarepartners.com/files/Bundling_Article_for_KCP.pdf

[phyrefly]

Calcitriol is part of the Medicare Bundle but only when you have Medicare as your primary insurance and you have part B. If you are Medicare primary and you have part B, contact the pharmacy to let them know they billed it wrong.

[Shaks24]

I am on medicare b and it is primary. I discussed this with my PD nurse this week. She advised me to bring the bill in and give it to the clinic social worker to correct. I will do so on doctor day at the clinic this coming Monday.