Medicare wants YOUR Comments About Home and Frequent Dialysis

[Zach]

The Centers for Medicare & Medicaid Services released its 2017 proposed rule for the Prospective Payment System and Quality Incentive Program on June 24. Part of the rule included new language regarding payments for training for home dialysis and payments for more frequent hemodialysis.

As an example:
For training, Medicare proposes to nearly double the add-on payment per session for peritoneal dialysis (PD) and home hemodialysis (HD) from $50.16 to $95.57 (intending to represent 2.66 hours of nursing time, a volume-weighted average assuming 2 hours for PD and 4 hours for HD), and for HD clarifies that all weekly training sessions are payment-eligible (as is already the case with PD).

You can download the complete rule here:
http://www.nephrologynews.com/wp-content/uploads/2016/06/PPS-QIP-proposed-rule.pdf

Formal comments are due by Aug. 23. 

[kickingandscreaming]

OMG! What a byzantine and unreadable document that is!  No wonder nothing improves in this world.  I really tried to read it and sort of managed through 50 pages.  So much governmentese language.  If I read enough of it to leave a comment, my brain would be totally and permanently fried.

[Charlie B53]

We need an interpreter.

There needs a Congressional Law that all such documents be written in clear language, understandable to the masses.  How can We, the People, know what the Government Departments are doing when everything is clouded in obscure language, designed to frustrate and confuse anyone that attempts to read and understand it?


The answer is clear.  They do NOT want We, the People to know what they are doing.

[Simon Dog]

We need an interpreter.

You are dealing with an organization that defines an egress as an entrance to an exit, and describes bullet wounds as ballistically induced subcutaneous apertures.

Of course, you could always dig into the tax code.

I did learn something interesting from the document - how Medicare pays for home hemo (assuming the procedure in the document matches the present).  The amount per home treatment is less, but adjusted so one week of home treatment gets the same payment as 3 in center treatments.     The center is still paid on a per-treatment basis (not on the basis of how many supplies and ancillaries you order).  It also mentions that medical justification is required for more than 3 treatments per week.   I guess this explains why the center had some work to figure out in the billing when I did a couple of extra treatments.

[Charlie B53]

We need an interpreter.

You are dealing with an organization that defines an egress as an entrance to an exit, and describes bullet wounds as ballistically induced subcutaneous apertures.

Of course, you could always dig into the tax code.

Exactly my point.   Congressional Members do not actually talk using language like this.  I do not believe anyone does.   This is purposely written in this manner to create confusion in the masses so to prevent the general public from knowing exactly what the real intent of the document is.   Many creating 'Codes' which Police are then forced to uphold, arresting people for things they never had a clue that constitute a 'crime'.

Recent case in point, the Lady in a suburb of East St Louis, arrested, cuffed, and transported for NOT mowing her yard.   A 'Code' violation.   Why wasn't a simple ticket issued?   She is Black.   Many of those community budgets are unwritten by the fines imposed on unknowing Blacks.    It is just WRONG.

Most ALL Legislation, Codes, et., written in language such as this should be over-turned, unenforceable until rewritten in Clear Language such that the common Man can understand.

[PrimeTimer]

Wonder how much dialysis providers are having to pay their lawyers to decipher this stuff. And sure, they can read it online but probably print it out. The govt is the biggest killer of trees. 

[cbatsea]

I see on our Medicare statement that they're being charged in excess of $4700 per treatment...and that's with ME doing it...no trained nurse or facility....we're at home, and I'm essentially "free" labor.  It's outrageous.

[Simon Dog]

I see on our Medicare statement that they're being charged in excess of $4700 per treatment...and that's with ME doing it...no trained nurse or facility....we're at home, and I'm essentially "free" labor.  It's outrageous.

Charged, but they are only paid the Medicare allowed amount (about $300).

DaVita did manage to collect $10,100 for two in-center treatments when I was traveling and still on private insurance.   

[solid98]

I see on our Medicare statement that they're being charged in excess of $4700 per treatment...and that's with ME doing it...no trained nurse or facility....we're at home, and I'm essentially "free" labor.  It's outrageous.

My mother, who is in a "long term care facility" (nursing home), has her toenails clipped by a guy who goes around to all the homes to do this service. He charges Medicare $125, per patient, to clip the nails and another $125, per patient, to travel to the home. So if he does 100 patients, he charges $12,500 to clip and another $12,500 for travel. According to moms Medicare EOB, they only pay him $35 total. Gotta love government work.

[Simon Dog]

My mother, who is in a "long term care facility" (nursing home), has her toenails clipped by a guy who goes around to all the homes to do this service. He charges Medicare $125, per patient, to clip the nails and another $125, per patient, to travel to the home. So if he does 100 patients, he charges $12,500 to clip and another $12,500 for travel. According to moms Medicare EOB, they only pay him $35 total. Gotta love government work.

He BILLS medicare the $125 each, but is PAID $35.   In this context, what he charges has nothing to do with what he gets paid.

[jcanavera]

I looked at our dialysis bill that was processed by Medicare.  Charge was about $112,000 for the month for peritoneal dialysis and all services.  Medicare accepted $8,600.  Private insurance payers are the cash cow for the dialysis service providers.  I remember for the few months prior to my wife going on Medicare, the insurance company was paying about $35,000 a month.

Jack

[Simon Dog]

Private insurance payers are the cash cow for the dialysis service providers.  I remember for the few months prior to my wife going on Medicare, the insurance company was paying about $35,000 a month.

In my pre-medicare days, my  insurance paid about $480 per treatment, but a couple out of town ones at a DaVita clinic were paid at $5050 each.   Fresenius only got $3000 per travel treatment.  At those prices, there should have been a happy ending.

[Charlie B53]

Curious, If Clinics BILL so much yet accept the smaller Medicare payment, then what becomes the difference?

Are they given a TAX WRITE OFF for the difference, thus off-setting income and NOT paying income tax?

There has to be some advantage for the system to be set up this way.  someone, is making a lot of money, somehow, and it isn't from the Medicare payments.

[Simon Dog]

Curious, If Clinics BILL so much yet accept the smaller Medicare payment, then what becomes the difference?

Nothing.

Every business has two costs for providing a service:

1. The fully burdened cost, which includes not only operational expenses (staff, supplies), but equipment amortization building rent, heat, A/C, etc.

2. The incremental cost of supplying one more customer

The medicare rate exceeds #2, but probably doe not exceed #1.  As such, it makes sense for clinics to accept medicare patients as long as they have enough private insurance patients to cover the fixed overhear.

[Shaks24]

I always figured it got them some kind of tax benefit. Its really crazy though when some months they bill upwards of 80k for PD then accept medicare's 3k or so as full payment. I'm only speculating on the tax issue. I just scratch my head and keep going on.

[Paul]

General rule of big business: Charge as much as you can without frightening off the customer. If they got big bucks, give them the big tab. If they don't got big bucks, work out the maximum they can afford, and charge them one cent less than that. They'll think they got a bargain, and pay up with gratitude.

[Simon Dog]

General rule of big business: Charge as much as you can without frightening off the customer. If they got big bucks, give them the big tab. If they don't got big bucks, work out the maximum they can afford, and charge them one cent less than that. They'll think they got a bargain, and pay up with gratitude.

Colleges have this down to an art.  Car dealers come in second place.

[cbatsea]

Medicare is billed $4159 per each home treatment we do.  They PAY about $219 per treatment.  We do 4 per week...the costs billed for his iron injections is astronomical.....and they do pay the entire amount for that.  The whole thing is insane.

[cattlekid]

I was one of those private insurance patients.  The clinic I started at did not offer home hemo with NxStage.  When I jumped ship to another clinic, the Facility Administrator came to my chair more than once *begging* me to stay.  I knew his  would be in a sling for letting me go.  I also got the same spiel from the clinic medical director, she basically told me that I was signing my death sentence to go to NxStage. 

From my reading I knew exactly how many Medicare slots I was keeping afloat with the astronomical amounts my private insurance was paying. 

As such, it makes sense for clinics to accept medicare patients as long as they have enough private insurance patients to cover the fixed overhear.

[Simon Dog]

From my reading I knew exactly how many Medicare slots I was keeping afloat with the astronomical amounts my private insurance was paying. 

Don't keep us in suspense ... how many.

I've always thought the private pay rate warranted happy ending dialysis. 

I also got the same spiel from the clinic medical director, she basically told me that I was signing my death sentence to go to NxStage.

Funny, the medical director at my clinic recently emailed me an article suggesting that more frequent hemo causes dialysis lifespan to approach that of a cadaver transplant.   His point was that I should hold out for a good KDPI.

[cattlekid]

By my figuring, my slot was bringing in about 10x more revenue per treatment than a Medicare patient.  Let's say for argument's sake that a Medicare slot loses just as much as they are being paid.  So 5 slots?  And this doesn't count what the clinic was actually billing, which we all know is a joke.  It's what my EOBs were showing that they were paying.

Let's just say that for the two years I was on dialysis, I blew through my insurance out of pocket maximum by January 15th of each year.  Thankfully I worked for a an extremely large multinational company so they never said boo about the amount of money I was costing them (we self insured).

From my reading I knew exactly how many Medicare slots I was keeping afloat with the astronomical amounts my private insurance was paying. 

Don't keep us in suspense ... how many.

I've always thought the private pay rate warranted happy ending dialysis. 

I also got the same spiel from the clinic medical director, she basically told me that I was signing my death sentence to go to NxStage.

Funny, the medical director at my clinic recently emailed me an article suggesting that more frequent hemo causes dialysis lifespan to approach that of a cadaver transplant.   His point was that I should hold out for a good KDPI.

[Simon Dog]

Let's say for argument's sake that a Medicare slot loses just as much as they are being paid.

There are two ways to calculate cost:

1. Average cost per treatment including all overhead

2. The incremental cost of adding another treatment

The Medicare payment is less than #1 but more than #2.   So, the clinic does not incur a loss by adding a Medicare patient.

Thankfully I worked for an extremely large multinational company so they never said boo about the amount of money I was costing them (we self insured).

It's all about internal cost assignment in the megacorps.  Your department was responsible for part of your premium and was not billed for your actual treatment so the cost was "invisible" to the person who decided your fate at the company.   A nice system if you can get in on it.

[Paul]

You want to try the pricing method the British NHS use when contracting services. Basically they say to the clinic/hospital: "Work out the absolutely cheapest possible price you can do it for, then halve it."

[cassandra]

You want to try the pricing method the British NHS use when contracting services. Basically they say to the clinic/hospital: "Work out the absolutely cheapest possible price you can do it for, then halve it."

And even than do Fresenius and Nxstage make a profit (unless I believe they love doing voluntary work and use the whole care system as one huge tax write off)