CMS Expects 1.2 Percent Increase in Dialysis Patient Co-Pays

CMS Expects 1.2 Percent Increase in Dialysis Patient Co-Pays
6 days ago by Keith Chartier , Editor 0 Comments
Posted in News, Centers For Medicare & Medicaid Services (CMS), Bundle Payment, Business, Government & Regulation, Practice Management, Kidney Patients, Dialysis Patient Citizens (DPC), Insurance
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WASHINGTON—Dialysis patients using Medicare can expect to see a 1.2 percent increase in their co-insurance payments largely due to the inclusion of laboratory tests into the new end-stage renal disease payment bundle, according to an analysis by the Centers for Medicare & Medicaid Services.

“The patient’s share of costs is likely to increase for most everybody because the 20 percent coinsurance for the bundle compared to the composite rate they pay now is going to be more because there are more services in the bundle ,” said Tonya Saffer, deputy director, Dialysis Patient Citizens. “For patients, who have a higher than average utilization of previously separately billable items like ESAs, CMS has theorized that there is a chance that overall their coinsurance or co-pays could be lower.”

Under the current system, Medicare beneficiaries on dialysis pay 20 percent of the dialysis base payment plus 20 percent of ESRD-related separately billable drugs, such as Amgen’s Epogen used to treat anemia. However, patients currently do not pay co-insurance on separately billable lab tests.

The new ESRD Prospective Payment System, released in July, bundles separately billable drugs, labs and the existing payments for dialysis services into one payment per treatment. CMS will pay for 80 percent of each treatment and patients will be responsible for the remaining 20 percent.

“As the beneficiary will be responsible for the co-insurance on the laboratory tests, we estimate they will have a 1.2 percent increase in their payments,” CMS wrote in the final rule.

Many of the 230 people who commented on beneficiary co-insurance obligations in the proposed bundle rule were concerned about the financial affects dialysis patient would see due to the co-pays that would result from the new bundled PPS.

“The commenters believed the new bundled PPS would increase beneficiary co-insurance and, therefore, would be a financial burden on patients, many who have limited income,” CMS wrote in the final rule.

One commenter on the proposed bundle rule noted that those with limited or fixed incomes may be subject to an additional $300 to $400 per year for co-insurance on laboratory tests.

Although CMS gave a general number for how much patients’ payments will increase, it did not break it down into types of patients or insurers. “[The bundle’s] impact [on out-of-pocket costs] will be hard to assess because everyone has different co-insurance arrangements,” Saffer said. “Some people are on Medicaid, some people don’t have co-insurance, others might have Medigap plans or other private supplemental insurance.”

In the past, CMS said there has “been an incentive for excess use of separately billable items and services” in the current payment system and that patients have always been responsible for 20 percent of their costs.

“If patients use less than the average of separately billable items and services (that is, items and services that were separately paid under the current basic case-mix adjusted composite payment system), they can expect an increase in their co-insurance obligation,” CMS wrote in the final rule. “However, if patients use more than the average of separately billable items and services, they should pay less in co-insurance under the ESRD PPS.”

CMS acknowledged in the final rule that the comparison doesn’t reflect the 20 percent co-insurance liability for non-routine lab tests. “However, we note that under the current basic case-mix composite rate system, certain routine laboratory tests are included in the composite rate,” CMS wrote in the final rule. “Therefore, beneficiaries have been responsible for co-insurance associated with ESRD-related laboratory tests that are included in the composite rate.”

According to the final rule, one commenter noted that in the law creating the bundle Congress did not indicate that the long-standing policy that Medicare paying 100 percent for laboratory tests would change under the ESRD bundled system.

“For all other Medicare beneficiaries, Medicare pays for 100 percent of labs,” Saffer said. “There is no cost sharing on laboratory tests. Everything in the bundle is subjected to co-insurance at 20 percent responsibility. So by adding more labs into the bundle patients are paying for tests they did not have to previously pay for. They are the only population under Medicare that has to pay for their lab tests.”

However, in the final rule, CMS wrote: “We note that most routine laboratory tests for ESRD-related purposes are currently included in the basic case-mix adjusted composite rate. This means that currently, beneficiaries with ESRD have a co-insurance liability for the composite rate, which includes laboratory tests. We do not see the inclusion of ESRD laboratory tests in the ESRD PPS as being any different than what occurs currently under the basic case-mix adjusted composite rate system.”

A few commenters were concerned about the negative impact the additional co-insurance would place on beneficiaries which may contribute to decisions to discontinue treatment, medications, etc. The commenters stated that many patients have difficulty in meeting the co-pays under the current system.

“I think the majority of patients are not aware of how this impacts their care,” Saffer said. “Despite people’s best efforts of trying to reach out and explain the issue, there is still greater need for education. It’s going to be a big surprise when all of the sudden your co-pays might increase without understanding what exactly happened.”

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