Era-Changing Letter Sent to Obama's Health Czar and CMS

Era-Changing Letter Sent to Obama's Health Czar and CMS

Gary Peterson - posts

   Posted 07 July 2009 04:00 AM
July 7, 2009 - An era-changing letter, written by some of the best known and prestigious nephrologists in the US, states that the annualized mortality rate for dialysis patients could possibly be reduced by 50% — saving approximately 50,000 American lives per year — by making dialysis treatment schedule changes. They conclude the “data is convincing” that longer treatments, possibly with shorter intervals between treatments, will greatly reduce the occurrence and severity of hypertension-related cardiovascular diseases that are a leading cause of death for dialysis patients.

RenalWEB has obtained a copy (see http://www.renalweb.org/documents/ESRD_Conf_Boston_Letter.htm) of the June 5th letter that was sent to President Obama’s healthcare reform czar Nancy-Ann DeParle and Dr. Barry Straube of the Centers for Medicare and Medicaid Services (CMS). It was sent from the Steering Committee of the April 23-26, 2009 conference “ESRD: State of the Art and Charting the Challenges for the Future,” which was held in Boston and was sponsored by the Harvard Medical School Department of Continuing Education.

It is shocking in today's medical environment that such dramatic improvements in survival are possible WITHOUT any new pharmaceuticals or technology breakthroughs. Tens of thousand of lives can be saved immediately with back-to-basics changes in corporate and government policies.

Besides the improved mortality rate claim, the letter makes several points that are likely to shake up current models of care for the nearly 400,000 US dialysis patients:

* Only 14% of current morbidity and mortality can be accounted for by assessing the CMS mandated clinical performance measures that dialysis facilities report (albumin, Ca, P, Kt/V, PTH, hemoglobin, etc). It was concluded that the system must address those issues that make the greatest difference in outcomes, not continue outmoded measurements that do not reflect quality of care. (Editor's note: Yet, independent dialysis providers must devote enormous amounts of effort and money to implement CMS's CROWNWeb program.)

* Longer and more frequent treatments can result in “vastly improved patient rehabilitation,” which is currently below 20%. Accordingly, it is strongly urged that the bundling payment system which is due to be implemented in 2011 should emphasize patient rehabilitation.

* Hemodialysis catheter use is tied to an increasing number of infections, higher mortality, and must be greatly reduced.

* The current formulas (Kt/V, URR) for prescribing and measuring the delivery of dialysis are insufficient. “The original premises on which both the concept and the mathematics are based are incorrect.”

* Sodium modeling likely adds to cardiovascular disease.

The committee concludes:

“Substituting longer, daily or nocturnal dialysis, performed at home or in-center, with greater attention to cardiovascular disease, infection, and a-v access is the roadmap for major improvement in care. The current reimbursement-delivery of care model does not acknowledge this need sufficiently.”

Editor's comment: Turning ocean liners around

There are three ocean liners that need to turn completely around for patients to enter this new era: CMS, Fresenius Medical Care, and DaVita. There are a number of personal and professional conflicts for individuals in each of these entities.

Nancy-Ann DeParle is a former director of the Health Care Financing Administration, the predecessor to CMS. DeParle was on the DaVita Board of Directors from May 2001 to July 2008. She earned more than $2 million in compensation and stock sales, according to records at the Securities and Exchange Commission.

I am impressed that the chief medical officers of the two major dialysis providers signed this letter as committee members. It is now up to the captains/CEOs of these companies to decide if they can morally continue on their current course. If they do not act, or act too slowly, they should not be surprised by the outrage and anger of the tax-paying public — or their own patients.

Finally, this letter also raises serious professional ethical issues for the physicians and nurses that receive profit-sharing or other corporate compensation based on outdated — and deadly — models of care.

For background information, see this RenalWEB report on the April 23-26, 2009 conference “ESRD: State of the Art and Charting the Challenges for the Future”.

URL: http://renalweb.groupee.net/eve/forums?a=tpc&s=6681030913&f=5911014023&m=647108722&r=647108722#647108722