Changes to Medicare's dialysis payment bundle included in Fiscal Cliff Bill

[Bill Peckham]

I am surprised to see significant dialysis payment changes included in the Senate Bill passed last night, I think it is HR 8 which is meant to address the spending cuts and tax increases due to take effect today. One part of the Bill addresses Medicare, what is commonly referred to as the 'doc fix', long story, but the point is Medicare was part of the Bill and part of the section on Medicare included this language about dialysis payments - the so called bundle under the ESRD program (from a PDF link to the 153 page full text):


SEC. 632.
REVISIONS TO THE MEDICARE ESRD BUNDLED PAYMENT SYSTEM TO REFLECT FINDINGS IN THE GAO REPORT.

(a) ADJUSTMENT TO ESRD BUNDLED PAYMENT RATE TO ACCOUNT FOR CHANGES IN THE UTILIZATION OF CERTAIN DRUGS AND BIOLOGICALS.—Section 1881(b)(14) of the Social Security Act (42 U.S.C. 1395rr(b)(14)) is amended by adding at the end the following new subparagraph:
‘‘(I) For services furnished on or after January 1, 2014, the Secretary shall, by comparing per patient utilization data from 2007 with such data from 2012, make reductions to the single payment that would otherwise apply under this paragraph for renal dialysis services to reflect the Secretary’s estimate of the change in the utilization of drugs and biologicals described in clauses (ii), (iii), and (iv) of subparagraph (B) (other than oral-only ESRD-related drugs, as such term is used in the final rule promulgated by the Secretary in the Federal Register on August 12, 2010 (75 Fed. Reg. 49030)). In making reductions under the preceding sentence, the Secretary shall take into account the most recently available data on average sales prices and changes in prices for drugs and biological reflected in the ESRD market basket percentage increase factor under subparagraph (F).’’.

(b) TWO-YEAR DELAY OF IMPLEMENTATION OF ORAL- ONLY ESRD-RELATED DRUGS IN THE ESRD PROSPECTIVE PAYMENT SYSTEM; MONITORING.—
(1) DELAY.—The Secretary of Health and Human Services may not implement the policy under section 413.174(f)(6) of title 42, Code of Federal Regulations (relating to oral-only ESRD-related drugs in the ESRD prospective payment system), prior to  January 1, 2016.
 (2) MONITORING.—With respect to the implementation of oral-only ESRD-related drugs in the ESRD prospective payment system under subsection
 (b)(14) of section 1881 of the Social Security Act (42 U.S.C. 1395rr(b)(14)), the Secretary of Health and Human Services shall monitor the bone and mineral metabolism of individuals with end stage renal disease.

(c) ANALYSIS OF CASE MIX PAYMENT ADJUSTMENTS.—By not later than January 1, 2016, the Secretary of Health and Human Services shall—
(1) conduct an analysis of the case mix payment adjustments being used under section 1881(b)(14)(D)(i) of the Social Security Act (42 U.S.C. 1395rr(b)(14)(D)(i)); and
(2) make appropriate revisions to such case mix payment adjustments.

(d) UPDATED GAO REPORT.—Not later than December 31, 2015, the Comptroller General of the United States shall submit to Congress a report that updates the report submitted to Congress under section 10336 of the Patient Protection and Affordable Care Act (Public Law 111–148; 124 Stat. 974). The updated report shall include an analysis of how the Secretary of Health and Human Services has addressed points raised in the report submitted under such section 10336 with respect to the Secretary’s preparations to implement payment for oral-only ESRD-related drugs in the bundled prospective payment system under section 1881(b) of the Social Security Act (42 U.S.C. 1395rr(b)(14)).


Section (a) is about EPO mostly but the way it is written it would include iron and injectable vitamin d. The EPO piece is the biggest part. The expanded payment bundle that went into effect Jan 2011 made assumptions about EPO use to come up with the payment amount - my memory of the final rule is it was assumed that EPO use would decline from ~5,700(mU/mL)/treatment to ~5,200/treatment but what actually happened was EPO use declined to <4,000/treatment I'm even hearing it was dropped to <3,000/treatment. You can think of each 1,000mU/mL of EPO as representing $10 of the bundle - the bundle included about $55/treatment for EPO. So if average EPO use is 2,000/treatment less by Medicare's reckoning the payment is $20 too generous. That said Amgen jacked their prices and Iron use has increased so some of that over payment has been shifted but clearly Congress expects CMS to lower the bundled payment rate for 2014.

Section (b) delays including binders in the bundled payment. Bassed on current law at the end of this year all dialyzors would receive their binders and calcimimetics (for instance Sensipar) from the dialysis unit. It is good that there is going to be a delay even though it is bound to create a lot of confusion.

Section (c) asks for a CMS review of the case mix adjusters, I'm not sure what exactly this is about but in the past talk of case mix adjusters meant looking at a race adjuster.

Section (d) wants CMS to say how they are fixing problems the GAO report identified.

Of course all of this might well never get signed into law because it is part of a big contentious piece of legislation but at some point the Doc Fix will get passed fixing the problem for another year and I think we should expect this language to be part of the fix under any circumstance.

[CebuShan]

Oh, great! More government crap to worry about!   

[cattlekid]

I would be thrilled if binders were kept out of the bundle permanently.  I am afraid that putting binders in the bundle would negatively affect the binder choices available to me.  Right now, I use a mix of Renvela and PhosLo and I could easily see where the more expensive binders like Renvela could be restricted. 

[boswife]

Please forgive me for being so 'unable to read through this'.  I'm not lazy, I just cant get a grasp on such things.  If anyone has a moment to simply write good and or bad out, I'd surly appreciate it................. but i don't expect it     I'm simple minded about such things and need 'money' matters laid out simply 

[Bill Peckham]

Please forgive me for being so 'unable to read through this'.  I'm not lazy, I just cant get a grasp on such things.  If anyone has a moment to simply write good and or bad out, I'd surly appreciate it................. but i don't expect it     I'm simple minded about such things and need 'money' matters laid out simply 

There are four sections - did you read my summary of each section ? The actual Bill text I have between the lines, and my explanation follows the actual text, maybe I should put the actual text in a quote box? but I find those harder to read.

Since I posted this I have heard that section C is thought to be needed because the providers aren't documenting all the comorbidities that CMS says are there so there is "reimbursement leakage". I also hear that this suspension of oral meds inclusion was not expected (at least not outside Amgen corporate offices). And I am hearing that overall Congress is scoring this as saving about 5 billion dollars over 10 years - which this Bill takes out of the ESRD program (it's applied to the doc payment fix).

[lmunchkin]

Boswife, It may be "Good" for the time being.  But "BAD" for our future generation.  I would have been willing to "fall off the cliff" and struggle through things now.  As it stands, we get an easy pass for now.  We are not concerned for the nonsense of this government.  I can't believe they can not budget their money.  But if you are not held to do so, you get what you get. All Partys are to blame.

Iam Praying for my children & grandchildren for the debt this generation is leaving.  Im going to do all I can to be sure I leave them something to get by on.  That is my focus now!  They will probably never have the opportunities in life that we have had. I hope Im wrong, but afraid Im right!

God Bless,
lmunchkin

[Bill Peckham]

This legislation passed the House and it will be signed by the President - it is the law of the land. Binders will not be included in the bundle until 2016 at the earliest, and the 2014 payment will be less than what it otherwise would be but it is hard to say how much less since the legislation allows CMS to look at price increases and drug usage changes across the bundle.

[Whamo]

The real funding crisis is coming up soon.  It's going to be a big drama, a big battle, and don't think the Middle class is going to win.  Obama threw the Middle class under the bus by raising their taxes while giving the rich huge inheritance tax breaks. 

[Bill Peckham]

The Kidney Care Partners has a statement out about Section 632. The way I read it they're agreeing that the legislation was necessary which probably means they believe they will be able to work the process to minimize cuts, maybe they can even work an effective increase if they can rebase the case mix adjusters. The potential sequestration cuts get a mention - a potential 2% cut - but I doubt anyone will be changing their position on sequestration based on the impact to dialysis reimbursement. No mention of the delay in including binders in the bundled payment which should be understood to mean thank you!


Following is a statement by Kidney Care Partners:
http://www.prnewswire.com/news-releases/kidney-care-provisions-in-fiscal-cliff-package-place-added-pressure-on-vulnerable-dialysis-patients-further-cuts-will-undermine-viability-of-many-dialysis-centers-185538262.html


WASHINGTON, Jan. 3, 2012 /PRNewswire-USNewswire/ -- The kidney care community is committed to being good stewards of Medicare dollars, which is why we believe the new dialysis payment system should reflect the total cost of caring for patients with kidney failure.  We also believe it is important to allow the experts, armed with the most up-to-date and accurate data, to work with the kidney community to accomplish this.

Provisions contained in the just-passed fiscal cliff package require a rebasing of the new Medicare dialysis payment system. Expected to save Medicare funds, rebasing comes on the heels of numerous cuts to dialysis funding, cuts that have resulted in tenuous economics for many dialysis facilities.  If implemented inappropriately, rebasing can have a devastating impact on vulnerable patients.  Access to high quality care for individuals with kidney failure also will be threatened if the fragile economics of dialysis facilities are further undermined by any additional cuts, whether through sequestration or other action.

Medicare covers 85 percent of the estimated 400,000 individuals receiving dialysis in America, making Medicare's funding of dialysis crucial to the health of the dialysis system.

We urge Congress and the Administration to protect the kidney care community from the looming sequestration cuts – and from any other cuts.

We also urge Health and Human Services (HHS) officials, in implementing the fiscal cliff legislation, to:

• Use the most recent data on utilization and costs
• Examine the payment system holistically
• Address other flaws in the calculation of Medicare dialysis payments

By working with the kidney care community to implement these provisions and by avoiding sequestration-related cuts, the federal government can assure continued high quality care for individuals with kidney failure who depend on dialysis to live.

[lmunchkin]

I recieved my first paycheck since the passage of this. Of course, my insurance premiums almost doubled (Employeer). I was given a choice there, so it was no surprise to me.  Then my soc. security & medicare prem we all pay in, went up too.  In my opinion, those are not entitlements, they are for future retirement & insurance benefits(Medicare).  So far, so good.

On the other hand, my small employer is not hiring full time right now.  My boss told me that he would love to, but right now with sales down and uncertainty in the market, he would hold off till improvements are seen. I personally think that we should be fine for right now at work. If no increase in sales, then someone will be laid off or hours will be cut.  They would have to go quite a ways back to reach me, but I would be willing to go before the others if they furnished my insurance.  Don't see that as a possibility & Im not so sure they would let me do that anyway.

All I truly know, is what is in my heart.  I want this Debt up there paid.  We need to avoid bankruptcy at all cost!  If that means bread & water, or beans & rice, then so be it.  Please for future generations sake, let Washington hold to the fire, as we have been made to. Ive said it be for and Im saying again, this has been coming for years now.  No one party is to blame.  Lets get this spending under control before it is too late!

Jesus Is Lord & Savior of my Life,
lmunchkin