I Hate Dialysis Message Board
Dialysis Discussion => Dialysis: General Discussion => Topic started by: okarol on July 05, 2013, 12:44:49 PM
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Cuts Could Mean Loss Of Dialysis Care For Thousands Of Americans
Hundreds of thousands of Americans who need dialysis care could lose that service next year.
That’s if a plan to cut almost 10 percent from costs of drugs used in a dialysis care pass.
If you want to read more about the plan, you can see the compete Medicare report at
this site http://ofr.gov/ofrupload/ofrdata/2013-16107_pi.pdf
If you want to voice your opinion about the plan to cut suppport for dialysis patients, you can do so online.
Just go to this site http://www.regulations.gov/#!home Follow the links to submit a comment.
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I can't read this Karol. It makes me sick to think about it!
lmunchkin
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Makes me sick too :puke;
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I can't read all of that but I did skim through. I'm not seeing where we would lose access to care. Not saying it's not there but could somebody explain this in layman's terms and give us the short version?
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Short version: The payment your center receives for each treatment and each drug will be cut by some percentage. The centers will have to find a way to make some money even though each patient is paying less. They could get less trained staff, cut back on the drugs you get, cut back on your treatment time, try to not take the worst patients, be cheap with supplies, etc. you imagine the options. In the long run, some centers may go too deeply into the whole to survive and will close. Other centers may never open.
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I guess if they can't make millions off us they will close. Maybe someone will stay open for a profit of hundreds of thousands.
I hope.
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Page 33, 2nd paragraph, "While we propose to implement the full reduction in CY 2014, we note that we are also
concerned that this one-time reduction to the ESRD PPS base rate could be a significant
reduction to ESRD facilities for the year and potentially impact beneficiary access to care."
If they admit they are concerned they're pretty sure there will be a problem. These are the guys who think everything they do will work. Lots of references to cuts driven by the Affordable Care Act. Put rules in place to reduce the number of people recieving treatment and overall dialysis cost to the system will come down.
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Cowdog, you are amazing being able to read that so carefully. My attention span runs out.
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I am in the Uk and thank God for the NHS. :bandance;
I have been studying a little and could be wrong but maybe my friends in the us should take a look.
So I had a vascath line in for 6 yers after my transplant failed. machine speed 450; clearance kt/v 1.8 I had a fistula done and its a baby so cannot do high pump speeds. using little orange needles. pump speed 200, they just did monthly bloods and my kt/v is 1.4. That's .4 difference. My point is:
1: we should try to use fistulas where possible,
2: change our diet so we don't need as much dialysis,
3: I am not saying this is good but I go to the sauna to remove fluids and some toxins, maybe a little change of life style would help.???
your thoughts friends... all welcome.
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Looks like the government is cutting health benefits anywhere they can. Don't worry, though, the trillions hidden offshore are safe from the government.
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Short version: The payment your center receives for each treatment and each drug will be cut by some percentage. The centers will have to find a way to make some money even though each patient is paying less. They could get less trained staff, cut back on the drugs you get, cut back on your treatment time, try to not take the worst patients, be cheap with supplies, etc. you imagine the options. In the long run, some centers may go too deeply into the whole to survive and will close. Other centers may never open.
In other words, they will continue what they have been doing for years.
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Cuts Could Mean Loss Of Dialysis Care For Thousands Of Americans
Hundreds of thousands of Americans who need dialysis care could lose that service next year.
That’s if a plan to cut almost 10 percent from costs of drugs used in a dialysis care pass.
If you want to read more about the plan, you can see the compete Medicare report at
this site http://ofr.gov/ofrupload/ofrdata/2013-16107_pi.pdf
If you want to voice your opinion about the plan to cut suppport for dialysis patients, you can do so online.
Just go to this site http://www.regulations.gov/#!home Follow the links to submit a comment.
I think too much Epogen is being given, I think this is more about profits than anything else. I cannot work up any sympathy for Davita @ $118.00 per share(Wall Street Journal). I was at Davita for five years, they have always been cheap.
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Please don't use a sauna unless you know what you're doing. You could hurt yourself.
I agree patients should watch their diets and take care of themselves. But it's hard to be perfect.
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Somehow the Italians have been scraping by on a lot less than we spend here:
"Italy has one of the lowest mortality rates for dialysis care -- about one in nine patients dies each year (in Italy), compared with one in five here. Yet Italy spends about one-third less than we do per patient.
http://www.propublica.org/article/in-dialysis-life-saving-care-at-great-risk-and-cost
Kent Thiry may have to skimp on his parties - pity:
http://www.5280.com/magazine/2012/09/strangest-show-earth
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I just don't even know how to deal with this anymore. I'm so tired of being a second-class citizen because I was born with kidney disease. I can't go back to work even after my transplant because the encephalitis I had really damaged my brain. But of course I will have to constantly prove I am disabled and in a few years they will decrease the amount I get on disability. I wish I felt some hope for my future but I don't.
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For those who don't want to slog through it, here's the short version.
This is all about drugs like iron and Epogen.
When the bundle was first proposed, Medicare had statistics on how much drugs were being used by the clinics and what they cost. They took that into account when setting the bundle price. After the bundle was instituted, clinics cut way back on the amount of drugs they were giving to patients. In response to the cutbacks by the clinics, Medicare is cutting their reimbursement. They aren't using as much, they won't be paid as much.
The background on this is that Medicare used to pay clinics for the cost of the drugs they bought, plus an extra fee meant to cover the costs of giving those drugs. This meant that the more drugs clinics gave, the more profit they made. There have been several high-profile lawsuits charging that clinics had corporate policies in place to maximize the amount of drugs both given to patients, and the amount thrown away. Because they made a profit on whatever they bought.
So the government decided to put a stop to that particular gravy train, and ordered that the drugs be included in one set price. So obviously the clinics ended their policies of "using as much as possible", and went to a policy of "using as little as possible". (There were several stories on IHD of people who used to get Epo in the lines during dialysis, who were abruptly told "You're getting injections now". Epo is far more effective when injected under the skin than when given IV.) Drug usage dropped like a rock, and so did the cost to the clinics.
So now Medicare looked at that and says "Since your costs have dropped so much, we are not going to pay you as much."
This cut is a reaction to cuts in care that have already happened - not a cause of them.
Of course the corporations are organizing petition campaigns and the like - they want to protect their profits. After all, they have shareholders to think of!
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Well put Rocker. The advocacy messages I've been seeing have been pretty bad, they're all along the line, the cuts would be devastating, don't make the cuts. It reminds me of the comments to the proposed bundle in 2010 that were along the line, the bundle is bad, do not bundle. In 2010 those sort of comments had zero effect and I believe those sort of comments will have zero effect today. It is almost as if the LDOs that set the community's advocacy agenda don't want any changes to the proposed cuts. As if they want the consolidation that will result if the proposed rule is finalized as is ... but wait that's just me being cynical ::)
I think there were some very good comments in 2010 that had an impact but it seems as if the community has forgotten the lesson of what makes for a good comment. You have to make specific points based on the legislation and the legislation that went before it. Not just say it is bad, or that CMS is crazy. CMS is bound by law to act on legislation passed through Congress and signed by the President, it has to rebalance the payments, just as it had to institute a bundle. COmments could have the effect of mitigating the cuts but those aren't the sort of comments the community seems intent on making.
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Thanks for explaining this. I was very confused as to why people are complaining about less payments. My payments are $3000 per treatment; that's $3000 x 5 = $15,000 a week. You do the math for the year. Luckly, Medicare is my primary and my job insurance is my secondary because I would not have a job because my treatments will run my job broke. Anyhoo, Medicare is not paying $3000 per treatment and Davita cannot charge me or my insurance company the balance. It's against the law as long as I am under Medicare. ::)
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Rocker, you are absolutely right, and NDXUfan, and too much epogen is not being used. Since a stop was put on the providers being able to milk the system on payments for epo, blood transfusion rates for dialysis patients have increased, i.e. people are not being given enough epo.
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Rural dialysis centers whether belonging to the large dialysis organizations or some of the remaining independents and smaller dialysis organizations will likely experience the greatest impact. Medicare reimbursement is already barely covering costs at present. It is undeniable that a nearly 10% cut will severely impact care for 400,000 dialysis patients whose primary provider is Medicare.
Unfortunately, CMS is likely to place a deaf ear to these cuts since it was not only the bundle that is promoting this, but the recent American Taxpayer Relief Act (ATRA). The recourse to lobbying CMS is of course going to congress for action. However, with CMS responding to the recent ATRA legislative act, they are also likely to have a deaf ear to advocates demanding they rescind these cuts. Long and short, the cuts are likely to stay especially given the overwhelmingly apathetic dialysis population where only a very small percentage of patients are involved in dialysis advocacy.
This will only fuel the already rampant consolidation of the dialysis industry. A few years ago, the feds kept changing the the standards on indwelling below ground gas tanks for gas stations. Stations had to upgrade to a new tank and rip up the old and install a new. Soon after, they had to do it all over again when the standards were upgraded again a relatively short time later. The mom and pop gas stations essentially disappeared when they could no longer afford to keep up with the latest regulations. The relationship between government regulations and industry consolidation is evident over and over again.
http://www.nytimes.com/1989/06/19/us/fuel-leak-rules-may-hasten-end-of-mom-and-pop-service-stations.html
The dialysis industry unfortunately, aided by congressional legislative action continues to march along this path to dialysis monopolies.
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...... My payments are $3000 per treatment; that's $3000 x 5 = $15,000 a week. You do the math for the year..... ::)
Well, not really. That $3k price is the price they might charge to those who have no insurance. In reality, Medicare sets the price that they are going to pay, and that's what they pay, not a penny more or less. The price you mention (and that they post on certain paperwork) has no reflection in reality. It's like the prices they post for furniture; nobody actually pays full price. After sales, discounts, deals, etc., people pay a LOT less than the 'posted price', and as a result, they think they've scored a big deal, when in fact, they've more or less paid what anybody else would.
In reality, Medicare pays something in the region of $500/$700 per dialysis session average.
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In reality, Medicare pays something in the region of $500/$700 per dialysis session average.
If a dialysis patient has private or group health insurance, it is the primary payer for the first 30 months of dialysis. The dialysis provider can CHARGE whatever it wants and in the majority of situations, works out a negotiated payment with the insurance companies. It is much much more than what medicare approves.
Now, after 30 months Medicare becomes the primary payer and a patients health insurance becomes secondary. Medicare's APPROVED RATE per treatment is $200-$350 depending on what area of the country you live. It PAYS 80% of that approved rate. Patients are responsible for the 20% balance.
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Long and short, the cuts are likely to stay especially given the overwhelmingly apathetic dialysis population where only a very small percentage of patients are involved in dialysis advocacy.
ESRD patients are some of the worst at self advocacy. Vast majority would rather bitch, moan and play the victim role as opposed to actually trying to do something constructive. Interestingly, over half already rely on some sort of government subsidy/entitlement such as food stamps, title 8 housing, medicaid, etc. Demographically, dialysis patients are not an influential subset of population.
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Long and short, the cuts are likely to stay especially given the overwhelmingly apathetic dialysis population where only a very small percentage of patients are involved in dialysis advocacy.
ESRD patients are some of the worst at self advocacy. Vast majority would rather bitch, moan and play the victim role as opposed to actually trying to do something constructive. Interestingly, over half already rely on some sort of government subsidy/entitlement such as food stamps, title 8 housing, medicaid, etc. Demographically, dialysis patients are not an influential subset of population.
Nor are we a large group either. At 400,000, we are costly but lack the numbers to influence our own outcome even if we were vocal and effective advocates. Nevertheless, that is not an excuse for us to not do more.
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Nor are we a large group either. At 400,000, we are costly but lack the numbers to influence our own outcome even if we were vocal and effective advocates. Nevertheless, that is not an excuse for us to not do more.
The largest components of the dialysis population are the elderly/blacks/latinos. AAKP made a huge mistake in the 1980-1990s by not partnering w/AARP and NAACP. Could have been vocal and effective advocates for us. Turf protection and hubris. But then again, forward-thinking has never been a descriptor for AAKP - even during the days of Dr. Lundin.
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I'm not happy with the general characterization of dialysis patients as apathetic or complainers or welfare bums or whatever. When I first started dialysis I spent the first 6 months or so in total shock and still quite ill. I went to dialysis, felt sick for hours, then tried to survive until the next session. It took months until I could think of anything but my own immediate needs.
Then I remember the population at my center. So many were old and wheelchair bound, even some coming in on a stretcher by ambulance, from the local state funded nursing home. I can't imagine some of them could advocate for more coffee at breakfast. Others were slightly younger or more independent. Many of those were poor people from our local very poor inner city. From their speech it seemed they weren't very well educated. Many in my center had other problems like diabetes or heart disease.
At my center to me it seemed like only about 3-4 of us on my shift had the education, energy, and resources to think about advocacy. Then if you have depression like I do, sometimes you have to focus on taking care of yourself. It's really hard to fight against big government. I know every time I contact my rep, I get a letter back basically telling me to get lost because they don't care about us little people. It's discouraging.
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I'm not seeing apathy so much as dialyzors tuning out the providers. Since 2011 the providers received a per treatment payment that was 10% more generous than the payments they received pre-bundle - how was that extra revenue used? Were there improvements in care? Was staffing improved? More/better supplies? Not the I have heard.
What I recall from the last two and half years are complaints about the payments rate; complaints about the sequester cut; complaints about the QIP withhold; complaints about the case mix adjusters. I think the providers are suffering the effects of crying wolf every three months and now that there really is a wolf no one is listening.
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Well, we could certainly chew the fat a bit on what apathy is and whether that applies to the dialysis population, but just looking at one dictionary definition, it seems to fit:
ap·a·thy (p-th)
n.
1. Lack of interest or concern, especially regarding matters of general importance or appeal; indifference.
2. Lack of emotion or feeling; impassiveness.
No doubt, when you are poor, elderly and undergoing dialysis in the usual fashion of in-center rapid ultrafiltration and short dialysis sessions, yes, simply surviving is what most do from session to session. Dialysis patients demographics are just that, mainly poor, elderly and debilitated patients. In addition, the culture of "compliance" within centers and retaliation for even minor exercises of independence does further promote a very passive patient group.
Thankfully, it is indeed a broad over generalization and there are obviously very active and concerned patients who take dialysis advocacy very seriously. Unfortunately, our numbers are few and far between and our financial resources are even more fragile. As a political entity, a dialysis lobby made up of patients is a group largely ignored by those who have the power. We not only have to deal with convincing doctors, nurses and techs of the clinical benefits of optimal dialysis, but in addition, we must lobby congress and CMS to ordain them since dialysis care belongs to the government.
Belding Scribner devoted his last few decades to just such an endeavor and never saw it come to fruition. I personally believe our greatest hope lies in technological breakthroughs with portable dialysis machines in an open market place competition. Until home hemo becomes a profit center for dialysis corporations promoting their new toys, I see little chance of any major improvements in the American dialysis experience.
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Maybe the government can increase ESRD cost savings by encouraging transplantation utilizing the lifelong immunosuppressive drugs kidney transplant act.
This approach will benefit all parties and create a much healthier and productive group.
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Maybe the government can increase ESRD cost savings by encouraging transplantation utilizing the lifelong immunosuppressive drugs kidney transplant act.
This approach will benefit all parties and create a much healthier and productive group.
The lifelong immunosuppressive drugs kidney transplant act topic was brought up before with Noahvale asking IHD patients to show support for it. Seems he didn't make a good enough argument for Bill Peckham, who is against its passage.
http://ihatedialysis.com/forum/index.php?topic=28786.msg454987;boardseen#new
Maybe you would contribute your thoughts.
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There is a lot providers can do to increase the transplant rate among their patients - a unit's transplant rate is reported in DIalysis Facility Reports that are available through the Pro Publica site. THe Northwest Kidney Centers transplant rate is 79% higher than the national average because they work to get their patients transplanted. NKC is coordinating care even though they aren't actually paid to keep in close contact with the transplant hospitals. NKC does it because it is the right thing to do - if more providers did what was right with the excess payments over the last few years maybe they'd be getting more support from patients.
The lifelong immunosuppressive drugs kidney transplant act topic was brought up before with Noahvale asking IHD patients to show support for it. Seems he didn't make a good enough argument for Bill Peckham, who is against its passage.
http://ihatedialysis.com/forum/index.php?topic=28786.msg454987;boardseen#new (http://ihatedialysis.com/forum/index.php?topic=28786.msg454987;boardseen#new)
Maybe you would contribute your thoughts.
In April as a result of that thread, I heard from a lobbyist that has worked with the AOPO and ASTS for the last few years, she made her case for Immunosuppression Coverage through Medicare, I was not impressed. The argument she made boiled down to "the Medicare immunosuppressant coverage is still needed as a wrap-around for those not in states where a benchmark plan would cover the drugs" but my point is all the benchmark plans cover immunosuppression meds. That's been my point all along. I really can't understand how one can offer fixes to legislation they haven't bothered to understand. But I suppose that's the root issue - immunosuppression meds through Medicare isn't meant as a fix to the ACA, to the transplant community the ACA never happened.
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I read Bill's argument against the extra drug coverage. While I understand what he's saying, I don't believe we can count on the Affordable Care Act actually being around after the next election. There are too many politicians trying to repeal it. They get great insurance coverage in Congress and think the rest of us don't deserve any help. It must be nice to have everything in your life work so great that you believe you'll never have any problems with illness.
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I hope and pray Obamacare is repealed along with the other repressive taxes of this administration. My only taxable income is my social security and now my health care coverage. By next year, with all of the tax bills of the last few years, I will be paying about $5,000 a year. Once again, this is tax to my social security on my health care coverage which is now counted as income.
My current health care coverage has sky rocketed to $35,000 a year for me and my wife through Group Health. I am grateful for the benefits of working for Kaiser, but I am not sure I can "afford" these "benefits" much longer. Of that, I will pay a straight 15% with no deductions in social security tax on my health care. What part of the "Affordable" part of Obamacare is it that we are supposed to cheer? What part of his "income redistribution" should I cheer? Health care costs have risen dramatically under Obamacare, people are losing health care and employers are changing to part time positions with NO benefits. The heart of Obamacare is exactly as Roberts stated, it is a tax and a HUGE tax.
It gets worse, if I live to be 65, then my small retirement from Kaiser will kick in. I truly believe at that time I will have to get a job just to pay my state and Federal taxes. Sorry, I am no fan of this president and what he has done to this country. Soon, all of America will look like Detroit.
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What part of his "income redistribution" should I cheer?
Matthew 25: 37-40
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Hemodoc, why have your healthcare costs gone up so dramatically? Mine haven't, so why have yours? Which part of Obamacare had led to your higher costs? Here is a link to the timeline where one can see what will be implemented when; maybe this can guide you in your explanation as to why your rates have gone up so much.
http://obamacarefacts.com/health-care-reform-timeline.php
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What part of his "income redistribution" should I cheer?
Matthew 25: 37-40
Dear Rocker, funny, I just gave $5.00 to a disabled amputee vet in a wheelchair at Costco. Yes, indeed, INDIVIDUALS have a duty to their fellow man. Now, without getting into a huge theological discussion, socialistic and tyrannical taxation is not what Matthew 25:37-40 is talking about. It is instead a call to INDIVIDUAL caring and giving.
Matthew 25:37 Then shall the righteous answer him, saying, Lord, when saw we thee an hungred, and fed thee? or thirsty, and gave thee drink?
38 When saw we thee a stranger, and took thee in? or naked, and clothed thee?
39 Or when saw we thee sick, or in prison, and came unto thee?
40 And the King shall answer and say unto them, Verily I say unto you, Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me.
Once again, if you wish to discuss biblical finance, I can assure you that America's movement towards a tyrannical government by BOTH parties with their tax and deficit spending is not at all biblical. Send me a pm if you wish me to explain more since a lot of folks don't want to talk about the Bible here in IHD. Please remember, you brought up this topic.
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Hemodoc, why have your healthcare costs gone up so dramatically? Mine haven't, so why have yours? Which part of Obamacare had led to your higher costs? Here is a link to the timeline where one can see what will be implemented when; maybe this can guide you in your explanation as to why your rates have gone up so much.
http://obamacarefacts.com/health-care-reform-timeline.php
Sorry, but the dramatic rise in health insurance premiums is quite well documented. So much for the "affordable" part of the bill.
http://online.wsj.com/article/SB10001424127887324063304578522893554786084.html
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Hmmm...I couldn't access that article for some reason. I have to either pay for a subscription or open an account, which I am loathe to do as it just adds to those who want to send me e-mails asking me to spend money. LOL!
I'm truly not trying to get into a debate. I really am curious as to why Group Health has made your premium skyrocket. Is it really because of the ACA, or do you suspect they might be using its implementation as an excuse to raise your premium? What reason did they give you? Whenever I hear that insurance premiums are going to go up, I just can't shake off this feeling that, once again, Corporate America is doing sneaky things and blaming it all on anything other than their own greed.
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I know this isn't an easy thing to do, especially for a typical dialysis patient, but I think the important lesson here is we need to be as self-sufficient as possible. I'm not going to sit here and say the sky is falling because I've been hearing that my entire life. This is how politics work, they attempt to scare the little people. For example, every time our government is having a budget issue who does our government threaten first? The sick and the poor. The elderly. The people that can't help themselves. They threaten to cut into our social security and our medicare. This scare tactic has been going on for decades and it's a tried and true method, that's why they keep using it. You don't see Obama threaten the rich in his speeches, you don't see him threaten to cut into our overpaid politicians salaries. That would be political suicide for any president.
At the end of the day everything works out for the most part. I mean I don't think we are going to see dialysis units shutting down all over the place. Anything is possible but in the meantime why worry about it? More than likely we will all live to see another day and continue to get the treatment we need. Now I'm not saying the system isn't broken because it clearly is, I'm just saying the sky isn't falling.
I've realized the past few years since I got sick that (A) I have to take care of myself and (B) The government isn't on my side. I get a little morsel of a check every month that doesn't cover jack. It doesn't even pay half of my expenses, maybe not even a quarter. Without my wife I would be homeless or dead. Bottom line I have to protect myself. I'm not going to go rob a bank or hurt anyone to do it, but you better believe I'm going to do whatever I have to do to make sure my family and I are able to meet our needs. Lately I have been looking at income that is under the table. I think every able bodied person should pay their taxes and I think we should all try not to rely on the government, but the sick and the people that can't help themselves should be taken care of by our government. We have enough to deal with than to worry about our medical care not being covered or our already small SSI checks shrinking. In an ideal world the able bodied would take care of the less fortunate and our government would step up to the place and make sure we were OK. The reality is that we have to make sure we are OK. I've started stashing money away in places that are untraceable. If they find out we have any extra money at all they will just take it away. I need that security of knowing if sh*t does hit the fan or the sky does fall I can take care of myself and my family because even in the best of times this government isn't there to save our butts.
I don't know if that made any sense. Sorry for rambling. I didn't get much sleep last night so if what I'm saying seems out there please forgive me.
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I also want to note that I'm not exactly anti-government. I'm not hiding up in the mountains stashing away guns and joining the militia. I think there is a middle ground where a reasonable person can say our government sucks and try to come up with real ideas how to solve the problems. Our government is completely out of control and is wasting billions on non essential programs yet we have to worry that we might not get the life-saving care we need? I don't think you have to be nuts to see changes need to happen in our government, NOT "OBama Change" either. Real changes.
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I can't disagree with you, BattleScars. I don't think any government is going to save our butts, especially this Congress. But there are a goodly number of butts out there that probably do need saving. Maybe this is where local faith groups could step up, but even for them, caring for a dialysis patient and contributing to the costs would break their banks.
Why are we still using this employer-based health insurance paradigm, anyway? Isn't that a bit outdated? Also, if employers decide not to insure their employees, it's my understanding that the employees don't "lose their insurance", rather, they can now go to a health exchange so that they purchase a plan that suits their needs. That seems to offer more choice than having to take the insurance that your employer offers.
The dialysis/renal community will always be in peril as long as our treatment is based on profit.
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Hmmm...I couldn't access that article for some reason. I have to either pay for a subscription or open an account, which I am loathe to do as it just adds to those who want to send me e-mails asking me to spend money. LOL!
I'm truly not trying to get into a debate. I really am curious as to why Group Health has made your premium skyrocket. Is it really because of the ACA, or do you suspect they might be using its implementation as an excuse to raise your premium? What reason did they give you? Whenever I hear that insurance premiums are going to go up, I just can't shake off this feeling that, once again, Corporate America is doing sneaky things and blaming it all on anything other than their own greed.
Sorry, I don't have those answers for Group Health. I just recently sold our CA home and now am no longer a Kaiser patient. Kaiser is paying for my Group Health as part of my health care for life benefit in my retirement package with my medical group. The $35,000 is what Kaiser is contracted to pay to Group Health. I have no clue why it has sky rocketed specifically, but the promise that the "Affordable Health Care Act" would reduce premiums has never materialized. Just the opposite in fact. By 2016, I have read that the average premium for a family will be $20,000.
http://www.huffingtonpost.com/2012/05/15/health-care-costs-record_n_1516380.html
I know that when I am 65 if God willing I live that long, I will have to strongly consider giving up my Kaiser lifetime coverage and go with Medicare and Medigap coverage I will purchase if either are still available. Otherwise, I will on paper look like a wealthy retiree, when in fact, the majority of my taxable income will instead by my health care coverage alone. My accountant explained that the ACA will make that common for people who have health care benefits in one state and then move out of state where they will also be taxable income. There is a reason why Obamacare hired thousands of new IRS agents as part of the "health care" deal.
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I also want to note that I'm not exactly anti-government. I'm not hiding up in the mountains stashing away guns and joining the militia. I think there is a middle ground where a reasonable person can say our government sucks and try to come up with real ideas how to solve the problems. Our government is completely out of control and is wasting billions on non essential programs yet we have to worry that we might not get the life-saving care we need? I don't think you have to be nuts to see changes need to happen in our government, NOT "OBama Change" either. Real changes.
I absolutely, totally agree. I wonder how much money was spent in investigating the IRS because some Congresspeople thought it would look good to be chasing what turned out to be non-existent villains? It's all about getting re-elected, and I don't care which party you're in.
Government no longer serves the people, at least not in the US.
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Sorry, I don't have those answers for Group Health. I just recently sold our CA home and now am no longer a Kaiser patient. Kaiser is paying for my Group Health as part of my health care for life benefit in my retirement package with my medical group. The $35,000 is what Kaiser is contracted to pay to Group Health. I have no clue why it has sky rocketed specifically, but the promise that the "Affordable Health Care Act" would reduce premiums has never materialized. Just the opposite in fact. By 2016, I have read that the average premium for a family will be $20,000.
http://www.huffingtonpost.com/2012/05/15/health-care-costs-record_n_1516380.html
I know that when I am 65 if God willing I live that long, I will have to strongly consider giving up my Kaiser lifetime coverage and go with Medicare and Medigap coverage I will purchase if either are still available. Otherwise, I will on paper look like a wealthy retiree, when in fact, the majority of my taxable income will instead by my health care coverage alone. My accountant explained that the ACA will make that common for people who have health care benefits in one state and then move out of state where they will also be taxable income. There is a reason why Obamacare hired thousands of new IRS agents as part of the "health care" deal.
I see. OK, thanks for that explanation.
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Dear Moosemom, the average cost in the exchanges for a family will be $20,000. How many folks of modest income can afford that?
http://www.huffingtonpost.com/2012/05/15/health-care-costs-record_n_1516380.html
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By 2016, I have read that the average premium for a family will be $20,000.
http://www.huffingtonpost.com/2012/05/15/health-care-costs-record_n_1516380.html (http://www.huffingtonpost.com/2012/05/15/health-care-costs-record_n_1516380.html)
Did you even read the article you linked to? The 20K is total healthcare spending through an employer group plan and the increase is not as high as in the past but the dollar amount is higher because a smaller percent of a large number is greater than larger percent of a smaller number. Peter since you are not a young healthy uninsured hipster your healthcare costs are not going to go up but I would wager that after 2014 when the ACA goes into effect the amount Kaiser has to pay Group Health will be considerably less because they will not be able to charge more due to your preexisting condition. Your situation to date has had nothing to do with the ACA but soon enough you will benefit from the ACA's provisions.
The bottom line total healthcare spending increased about 3.5 to 4% a year in 2009 through 2012 as opposed to 7 to 8% in the previous decade. That lower growth rate has made all sorts of issues around healthcare costs and coverage easier to deal with, those saving will continue to compound far into the future. For those of us who rely on Medicare the trust fund, in 2008 was due to go into deficit in 2016. Today it is due to go in to the red in 2028. That is due to Obamacare.
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Sorry Bill, we will have to agree to disagree. I don't believe your figures are accurate. Here are some more articles talking of the failed promise of Obamacare to reduce premiums.
http://thehill.com/blogs/healthwatch/health-insurance/272465-study-health-premiums-skyrocketed-compared-to-wages
http://www.svherald.com/content/news/2013/04/05/350620
http://freebeacon.com/obamacare-causing-insurance-premiums-to-skyrocket-in-indiana/
http://online.wsj.com/article/SB10001424127887323936804578227890968100984.html
Lastly, my Group Health coverage is a group rate, not an individual rate. Health care costs are NOT going down under Obamacare, just the opposite. In addition, the taxes are also going through the roof.
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Does any of this ObamaCare garbage even apply to me? I live in MA where we already have mandated health insurance. The sky hasn't fallen here once it was passed. If anything it may have saved my life. I didn't have insurance at all before I moved here and because of the laws here pre-existing conditions could not be a reason to deny insurance so I was able to jump on my wife's plan. I have read somewhere that once my 30 months is up on dialysis my insurance can make medicare pay for it all. Not sure what that's about. Anyways, I'm on dialysis and our medical costs aren't that expensive. I want to say my wife gets maybe $50 a week taken out of her check at most but I think it's even a lot lower than that. When she added me on it was only an extra $15 a pay check. My Rx copays are what I think are the most expensive. I can't see anyone average family paying $20K a year in premiums. I'm not trying to argue because I know next to nothing about any of this. My gut feeling is these are more scare tactics. What I don't get is if everyone is so against this Obamacare then why did you all vote for the clown? I had other reasons for not voting for him but you can't blame me on this one. I think he's one of the worst presidents in my lifetime. All those "Change" speeches were nothing but a smoke screen.
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BattleScars, not everyone is against Obamacare. Why would you think that? All of those "Change" speeches were based on the assumption that we had a Congress that really wanted to change the way things work in D.C. That assumption has proven to be false. Anyone who needs any kind of government support, like those of us with ESRD who rely on Medicare or Medicaid, will be left behind to rot.
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Sorry Bill, we will have to agree to disagree. I don't believe your figures are accurate. Here are some more articles talking of the failed promise of Obamacare to reduce premiums.
http://thehill.com/blogs/healthwatch/health-insurance/272465-study-health-premiums-skyrocketed-compared-to-wages (http://thehill.com/blogs/healthwatch/health-insurance/272465-study-health-premiums-skyrocketed-compared-to-wages)
http://www.svherald.com/content/news/2013/04/05/350620 (http://www.svherald.com/content/news/2013/04/05/350620)
http://freebeacon.com/obamacare-causing-insurance-premiums-to-skyrocket-in-indiana/ (http://freebeacon.com/obamacare-causing-insurance-premiums-to-skyrocket-in-indiana/)
http://online.wsj.com/article/SB10001424127887323936804578227890968100984.html (http://online.wsj.com/article/SB10001424127887323936804578227890968100984.html)
Lastly, my Group Health coverage is a group rate, not an individual rate. Health care costs are NOT going down under Obamacare, just the opposite. In addition, the taxes are also going through the roof.
I'm talking about total health spending - which is widely reported to being in the fifth year of record slow growth (http://www.medpagetoday.com/Washington-Watch/Reform/40755), confirmed for the 2009 - 2011 period (http://www.kaiserhealthnews.org/daily-reports/2013/january/08/health-spending-news.aspx) and early indications are that it is continuing in 2012 and 2013, to which your response is to Google up some articles about someone's premiums somewhere going up. I think your response suggests you don't have a strong understanding of healthcare economics.
In addition Peter, you seem to be saying Kaiser is paying Group Health 35K a year to insure you as part of a group rate, that would be extraordinary. More likely, based on common sense, since I don't know the details of your particular coverage, is that Kaiser is paying Group Health to cover you based on the fact that you have stage 5 CKD, which after January 1st Kaiser won't have to do that.
The one article you linked to that did have something to do with Obamacare - the freebacon article - references the Indiana numbers that the Republican administration there cooked up as best they could, but a quick google search will reveal why those numbers are suspect.
Obamacare is heere to stay and it is a big win for the American people, particularly Americans living with an illness
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Sorry Bill, I am talking about premium increases. The data is clear, they have gone up substantially and will continue to escalate BECAUSE of Obamacare. Adding in the fact that health care costs had stabilized, the premium increases under Obamacare since passed in 2010 speaks to the fact that Obamacare is anything but affordable.
http://www.nytimes.com/2013/01/06/business/despite-new-health-law-some-see-sharp-rise-in-premiums.html?pagewanted=all
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A couple of comments. I'm sure I'll get flamed to death but I feel compelled to make my thoughts known:
1. Due to some of the provisions of the ACA, the benefits provided through my employer-based health insurance have had to expand from previous levels ("free" birth control, covering "children" up to age 26 are two that I can think of off the top of my head). We already had no lifetime maximum on benefits. Our HR department, when presenting the new premiums for 2013, specifically told us that the increases in premiums were due to the ACA and its new provisions.
2. I was directly asked yesterday to sign a petition to go to CMS to ask Congress to repeal the cuts to dialysis providers. I replied to the individual who asked that UNTIL the day when I see LDOs step up and indicate that they will be cutting administrative costs and salaries (including the extremely bloated executive level salaries) instead of fearmongering on cuts to services, I do not plan on being the shill for an LDO. I'm sure the response I get to that one will be interested. I bet I will be accused of being willing to kill off Grandma and Grandpa.
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Short version: The payment your center receives for each treatment and each drug will be cut by some percentage. The centers will have to find a way to make some money even though each patient is paying less. They could get less trained staff, cut back on the drugs you get, cut back on your treatment time, try to not take the worst patients, be cheap with supplies, etc. you imagine the options. In the long run, some centers may go too deeply into the whole to survive and will close. Other centers may never open.
In case, you have not noticed, Davita and Fresenius are too cheap, already.
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1. Due to some of the provisions of the ACA, the benefits provided through my employer-based health insurance have had to expand from previous levels ("free" birth control, covering "children" up to age 26 are two that I can think of off the top of my head). We already had no lifetime maximum on benefits. Our HR department, when presenting the new premiums for 2013, specifically told us that the increases in premiums were due to the ACA and its new provisions.
I'm no expert on this particular topic, but here is how I see it: Not every woman on a private health plan is going to suddenly start taking the pill, so all in all, it really isn't going to cost that much more in the long run. Also, being on the pill is a hell of a lot cheaper than being pregnant and adding a newborn to the plan - who may or may not be healthy at the time of birth. A lot of women are on the pill for reasons other than contraception. I was on it during dialysis to control my period and hopefully not need as much epo, for example. And as for the kids up to age 26 - MOST of them (but certainly not all) are healthy - so the insurance company is getting a break by collecting premiums for them and little out-go in healthcare dollars. People that age are the "creme-de-la creme" in their eyes, so I am willing to bet they LOVE this part of the deal. If they are charging companies more for that gift the ACA gave them, then that is due to them wanting to make bank. Yes, there are exceptions to that rule, of course. There always is. I just feel that those who are the exceptions deserve to have healthcare rather than what the alternative is in our society - make them poor and desitute so they qualify for Medicaid and live a sad, depressing sick life. I hate what our country does to those who are sick, I really do.
KarenInWA
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I know our health premiums have gone up the last 2 years. they deduct $202.40 from each pay check there are 26 pay checks a years. That is for BCBS of Alabama, Cigna dental and some eye program (the dental and Eye is less than $27 a paycheck)
BCBS has a $35 copay for Dr. office visits, a $500 deductible at which point they pay 75%, and finally a $8000 out of pocket max per person with a 3 per person max per family. (this is the best insurance Lowe's now offers, there are 3 choices now)
Lowe's switched us to this from our wonderful local insurance 2 years ago
Winhealth (a local wyoming company) is what we had before it was $127 a paycheck for just Ed and I. If we had chosen family it would have been $168.90 a paycheck. Doctors visit copay was $30, they paid 75% of everything until you met your deductible of $500 dollars, then after deductible they pay %100. plus they were nice and easy to get answers from.
It is unclear whether Lowe's current plans will change next year, they do not meet the ACA requirements but if Lowe's had these plans in effect (somewhere in the company) before 2010 they will be "grandfathered in" HR rep is checking for us.
Our family is low income and our children were covered by medicaid and still are. I wish Wyoming would extend the medicaid because then Ed would be on medicaid also. I got on SSI and thus got medicaid in April. I couldn't imagine $16000 in hospital expenses between Ed and I.
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:cuddle;
Sorry Bill, I am talking about premium increases. The data is clear, they have gone up substantially and will continue to escalate BECAUSE of Obamacare. Adding in the fact that health care costs had stabilized, the premium increases under Obamacare since passed in 2010 speaks to the fact that Obamacare is anything but affordable.
http://www.nytimes.com/2013/01/06/business/despite-new-health-law-some-see-sharp-rise-in-premiums.html?pagewanted=all
Did you actually read your link? It doesn't sound like it.
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Hmmm...I couldn't access that article for some reason. I have to either pay for a subscription or open an account, which I am loathe to do as it just adds to those who want to send me e-mails asking me to spend money. LOL!
I'm truly not trying to get into a debate. I really am curious as to why Group Health has made your premium skyrocket. Is it really because of the ACA, or do you suspect they might be using its implementation as an excuse to raise your premium? What reason did they give you? Whenever I hear that insurance premiums are going to go up, I just can't shake off this feeling that, once again, Corporate America is doing sneaky things and blaming it all on anything other than their own greed.
Sorry, I don't have those answers for Group Health. I just recently sold our CA home and now am no longer a Kaiser patient. Kaiser is paying for my Group Health as part of my health care for life benefit in my retirement package with my medical group. The $35,000 is what Kaiser is contracted to pay to Group Health. I have no clue why it has sky rocketed specifically, but the promise that the "Affordable Health Care Act" would reduce premiums has never materialized. Just the opposite in fact. By 2016, I have read that the average premium for a family will be $20,000.
http://www.huffingtonpost.com/2012/05/15/health-care-costs-record_n_1516380.html
I know that when I am 65 if God willing I live that long, I will have to strongly consider giving up my Kaiser lifetime coverage and go with Medicare and Medigap coverage I will purchase if either are still available. Otherwise, I will on paper look like a wealthy retiree, when in fact, the majority of my taxable income will instead by my health care coverage alone. My accountant explained that the ACA will make that common for people who have health care benefits in one state and then move out of state where they will also be taxable income. There is a reason why Obamacare hired thousands of new IRS agents as part of the "health care" deal.
It doesn't sound like you actually read this link either. Reading is really fundamental.
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Hmmm...I couldn't access that article for some reason. I have to either pay for a subscription or open an account, which I am loathe to do as it just adds to those who want to send me e-mails asking me to spend money. LOL!
I'm truly not trying to get into a debate. I really am curious as to why Group Health has made your premium skyrocket. Is it really because of the ACA, or do you suspect they might be using its implementation as an excuse to raise your premium? What reason did they give you? Whenever I hear that insurance premiums are going to go up, I just can't shake off this feeling that, once again, Corporate America is doing sneaky things and blaming it all on anything other than their own greed.
Sorry, I don't have those answers for Group Health. I just recently sold our CA home and now am no longer a Kaiser patient. Kaiser is paying for my Group Health as part of my health care for life benefit in my retirement package with my medical group. The $35,000 is what Kaiser is contracted to pay to Group Health. I have no clue why it has sky rocketed specifically, but the promise that the "Affordable Health Care Act" would reduce premiums has never materialized. Just the opposite in fact. By 2016, I have read that the average premium for a family will be $20,000.
http://www.huffingtonpost.com/2012/05/15/health-care-costs-record_n_1516380.html
I know that when I am 65 if God willing I live that long, I will have to strongly consider giving up my Kaiser lifetime coverage and go with Medicare and Medigap coverage I will purchase if either are still available. Otherwise, I will on paper look like a wealthy retiree, when in fact, the majority of my taxable income will instead by my health care coverage alone. My accountant explained that the ACA will make that common for people who have health care benefits in one state and then move out of state where they will also be taxable income. There is a reason why Obamacare hired thousands of new IRS agents as part of the "health care" deal.
It doesn't sound like you actually read this link either. Reading is really fundamental.
Balderdash!
Health Care Costs To Exceed A Record $20,000 Per Year For Families With Insurance, Study Says
Health care costs for a family of four covered by workplace health insurance will exceed $20,000 for the first time ever this year -- $20,728 to be precise -- according to a new study released Tuesday. That's $1,335 more than in 2011.
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Sorry Bill, I am talking about premium increases. The data is clear, they have gone up substantially and will continue to escalate BECAUSE of Obamacare. Adding in the fact that health care costs had stabilized, the premium increases under Obamacare since passed in 2010 speaks to the fact that Obamacare is anything but affordable.
http://www.nytimes.com/2013/01/06/business/despite-new-health-law-some-see-sharp-rise-in-premiums.html?pagewanted=all (http://www.nytimes.com/2013/01/06/business/despite-new-health-law-some-see-sharp-rise-in-premiums.html?pagewanted=all)
Health Care Costs To Exceed A Record $20,000 Per Year For Families With Insurance, Study Says
Health care costs for a family of four covered by workplace health insurance will exceed $20,000 for the first time ever this year -- $20,728 to be precise -- according to a new study released Tuesday. That's $1,335 more than in 2011.
So which is it, total healthcare spending? Or premiums? Because as the Huffpost article states the cost to the "typical" family of four is $5,114 in premiums for a preferred provider organization plan along with $3,470 in out-of-pocket costs. The article also points out "Family health care costs grew by 6.9 percent between 2011 and 2012, slower than in previous years" which is good and the news about federal healthcare costs are even better, as the links I provided report.
Pick one - healthcare costs to families - about $8,500/year - or healthcare cost to society from total spending point of view or the federal/state government's point of view?
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The topic is: Are we going to get cut off from dialysis or not?
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Sorry Bill, I am talking about premium increases. The data is clear, they have gone up substantially and will continue to escalate BECAUSE of Obamacare. Adding in the fact that health care costs had stabilized, the premium increases under Obamacare since passed in 2010 speaks to the fact that Obamacare is anything but affordable.
http://www.nytimes.com/2013/01/06/business/despite-new-health-law-some-see-sharp-rise-in-premiums.html?pagewanted=all (http://www.nytimes.com/2013/01/06/business/despite-new-health-law-some-see-sharp-rise-in-premiums.html?pagewanted=all)
Health Care Costs To Exceed A Record $20,000 Per Year For Families With Insurance, Study Says
Health care costs for a family of four covered by workplace health insurance will exceed $20,000 for the first time ever this year -- $20,728 to be precise -- according to a new study released Tuesday. That's $1,335 more than in 2011.
So which is it, total healthcare spending? Or premiums? Because as the Huffpost article states the cost to the "typical" family of four is $5,114 in premiums for a preferred provider organization plan along with $3,470 in out-of-pocket costs. The article also points out "Family health care costs grew by 6.9 percent between 2011 and 2012, slower than in previous years" which is good and the news about federal healthcare costs are even better, as the links I provided report.
Pick one - healthcare costs to families - about $8,500/year - or healthcare cost to society from total spending point of view or the federal/state government's point of view?
So, the cost of employee health insurance premiums to employers is unimportant and not in that mix Bill?
Where is the promise of your president that premiums would go down. Not true, up every year since signing the ACA.
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So, the cost of employee health insurance premiums to employers is unimportant and not in that mix Bill?
Where is the promise of your president that premiums would go down. Not true, up every year since signing the ACA.
Pick a topic premiums or total spending, and see if your world view can be supported by data. Show me the link where anyone promised premiums would go down as opposed to grow less fast.
Total costs are growing less fast, the ACA requires insurance companies to spend at least 80% of their incoming premiums on medical care, thus as total costs increase at a slower rate premiums will increase at a slower rate. It is a clear signal that you've lost perspective Peter when you write [premiums are] "up every year since signing the ACA" intending it as some sort of argument in support of your position. As if premiums and medical costs were in such a state of perfection prior to the ACA. You're suggesting premiums never went up prior to 2010, which is an incredible stance to take. Overall there is blindness evidenced in the President's political opponents, a blindness to the world as it existed and I would say as it exists. Historians will have to explain it someday.
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"Well, it’s been an interesting week in health care land. For a while now, independent analysts—and conservative critics—have raised concerns that Obamacare will dramatically increase the cost of individually-purchased health insurance for healthier people. This would, of course, contradict President Obama’s promises that “if you like your plan, you can keep it” and that the cost of insurance would go down “by $2,500 per family per year.” What’s new is that liberal columnists, facing reality, are conceding that premiums will go up for most people in the individual market. But they’re justifying it by saying that “rate shock” will help a tiny minority of people who can’t get insurance today. If they had said that in 2009, would Obamacare have passed?"
http://www.forbes.com/sites/theapothecary/2013/06/03/democrats-new-argument-its-a-good-thing-that-obamacare-doubles-individual-health-insurance-premiums/
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Obamacare in Georgia: Sticker shock
Posted: August 1, 2013 - 10:22pm | Updated: August 2, 2013 - 12:01am
GEORGIANS WHO will be forced to buy health insurance under Obamacare later this year should be prepared to dig deeply into their wallets — then hold on for dear life.
That’s because of heart attack-inducing sticker shock.
The premiums for the five health insurers that will be offering policies in Georgia’s federally run insurance exchange are “massive,” according to Georgia Insurance Commissioner Ralph Hudgens.
http://savannahnow.com/opinion/2013-08-01/obamacare-georgia-sticker-shock#.UgCH4Ryez88
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'Cheapest' ObamaCare Plans Aren't So Cheap After All
By John Merline, INVESTOR'S BUSINESS DAILY
Posted 08/02/2013 05:42 PM ET
The average price for the lowest-cost ObamaCare "bronze" plan in eight states is 122% higher than the cheapest plan currently available in those states, according to an IBD analysis of rate filings and a recent Government Accountability Office report.
The late July report, largely overlooked by the press, provides detailed information on insurance plans today in all 50 states, from the cheapest plans offered to a 30-year-old nonsmoker to the most expensive plans 55-year-old couples can buy.
Read More At Investor's Business Daily: http://news.investors.com/politics/080213-666235-cheap-obamacare-twice-as-costly-as-existing-plans.htm#ixzz2bADx07KP
Follow us: @IBDinvestors on Twitter | InvestorsBusinessDaily on Facebook
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Judging by your links, let make sure I understand - your main complaint is that healthy young
people males without preexisting conditions will now have to pay more for a basic policy than before in some states, if they're among those that buy their own insurance on the open market. And even though the plans these health young hipsters could buy today "often include higher deductibles and skimpier benefits than ObamaCare allows" and with Obamacare plans they'll have insurance that stays in effect when they get sick, this is a big problem. You're saying this is the main problem with Obamacare: it will impose higher costs to healthy young males who buy their own insurance (women are never included in these complaints because now their premiums have to be set at the same rate as males so they pretty much benefit across the board, even in Georgia).
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I was wondering what exactly the Forbes articel referenced with their quote saying the promise was premiums would be lowered by “by $2,500 per family per year.” ANd ther e is a youtube video withthe President repeting hte promise over and over again http://youtu.be/_o65vMUk5so (http://youtu.be/_o65vMUk5so) but you'll notice all instances of him saying this was during the 2008 campaign when he was talking about his plan for healthcare. BTW his plan for healthcare didn't include a mandate either Clinton's plan included a mandate, it was the primary policy difference between the two candidates.
As it turned out Congress sent a plan a lot more like Clinton's to his desk to be signed. So is that the complaint, that you wish the ACA had been more like Obama's plan that he campaigned on? In any case an average family of four that earn less than $50,000/year (average yearly household income) they'll be getting about $2,500 in subsidies though the exchanges and in the effect of slower growth in premiums.
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I was wondering what exactly the Forbes articel referenced with their quote saying the promise was premiums would be lowered by “by $2,500 per family per year.” ANd ther e is a youtube video withthe President repeting hte promise over and over again http://youtu.be/_o65vMUk5so (http://youtu.be/_o65vMUk5so) but you'll notice all instances of him saying this was during the 2008 campaign when he was talking about his plan for healthcare. BTW his plan for healthcare didn't include a mandate either Clinton's plan included a mandate, it was the primary policy difference between the two candidates.
As it turned out Congress sent a plan a lot more like Clinton's to his desk to be signed. So is that the complaint, that you wish the ACA had been more like Obama's plan that he campaigned on? In any case an average family of four that earn less than $50,000/year (average yearly household income) they'll be getting about $2,500 in subsidies though the exchanges and in the effect of slower growth in premiums.
Yes, and my taxes will continue to go up to pay for those subsidies even though my only taxable income is my Social Security and now my lifetime health care benefits. Sorry Bill, I am no fan of Obamacare. When it is fully implemented, I suspect a majority of folks will feel the same. When I am 65, I will likely have to drop my Group Health coverage and pay for a Medigap plan with my Medicare if it is not bankrupted yet. I simply won't be able to afford the taxes on my healthcare plan since I am still considered a partner of Kaiser from the IRS perspective. So, my higher taxes to pay for those subsidies will ironically cause me at some point to lose my own healthcare. Great system Bill.
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Rerun, I think you got ignored. I wish I knew what will happen to people on dialysis. Will our treatment be cut? What I personally wish is that more families would look honestly at whether their relatives should be on dialysis. There were always some patients in my center for whom it didn't make sense. If you're brought in on a stretcher and don't really know where you are, is dialysis really helping you live your life? So many are in denial about death. Grandma's life needs to be extended by that torturous year on dialysis. If as a society we get honest about that sort of thing, there might be enough money left to treat the rest. I don't mean "death panels." I mean doctors being willing to say the truth.
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Jeannea, Amen Sister!! But, as long as you have a pulse you are a money maker for these Dialysis Centers. Hamster on a wheel generating money. Sad but true.
Will these Dialysis Centers who make millions off sick people and Medicare really close their doors? We would start dropping dead after about a week. Are they really going to do this? I'm sure if they cut ALL Medicare they would close their doors and someone would step in but not in time. You know how fast Congress works.
Those on Home Dialysis better start hoarding supplies. The rest of us won't have a chance.
???
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Everyone is screaming at Medicare and begging Congress for help.
Am I the only one who thinks this is crazy?
http://ihatedialysis.com/forum/index.php?topic=29448.0 The companies are doing well.
I'm pretty sure they'll have to repeal Obamacare to get us out of this mess.
The money to pay for it is coming from ESRD patient care.
I think anyone can see that the gravy train has been very lucrative and it's an area that can afford cuts.
Sadly, the health providers are not going to cut their profit margins, they have shareholders they have to answer to.
It's the patient's who will end up shortchanged.
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No. As I mentioned upthread, I have blatantly ignored all of the cries for "advocacy" from all of the shill organizations for the LDOs.
Until the day comes where I see the top brass at an LDO publicly state that they are going to cut bloated administrative salaries or live with a lower profit margin (notice that I did NOT say "lose money", I said "lower profit") then they can go pound sand for all I am concerned. I am not their puppet and refuse to be used as such.
CMS still has a set of rules that all dialysis providers have to live by and these aren't changing to my knowledge. So instead of running around begging Congress for money, it might be time to brush up on the Conditions for Coverage and holding our clinics' feet to the fire instead. Don't let them get away with their scare tactics.
Everyone is screaming at Medicare and begging Congress for help.
Am I the only one who thinks this is crazy?
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Thanks cattlekid, I had missed your earlier post. :waving;
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Jeannea, Amen Sister!! But, as long as you have a pulse you are a money maker for these Dialysis Centers. Hamster on a wheel generating money. Sad but true.
Will these Dialysis Centers who make millions off sick people and Medicare really close their doors? We would start dropping dead after about a week. Are they really going to do this? I'm sure if they cut ALL Medicare they would close their doors and someone would step in but not in time. You know how fast Congress works.
Those on Home Dialysis better start hoarding supplies. The rest of us won't have a chance.
???
Actually, the two issues are quite related and intertwined. Those that opposed Obamacare to start with warned that Obama was going to raid Medicare and that cuts to the seniors would come shortly. The fact that we see these cuts beginning is not a surprise. Obama gutted Medicare to "pay" for the ACA.
http://www.breitbart.com/Big-Government/2013/02/20/With-Election-Over-Obama-Announces-Medicare-Cuts-To-Fund-ObamaCare
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I'm pretty sure they'll have to repeal Obamacare to get us out of this mess.
The money to pay for it is coming from ESRD patient care.
This isn't the case. Obamacare was paid for when the legislation passed - through some taxes and cuts to Medicare Advantage and payment rate growth decreases to large providers on the hospital side, taking note that the ACA has also extended the projected life of the Medicare trust Fund from 2016 (as was reckoned prior to 2010) to 2028 (as it is reckoned today), and as of next year the Part D Donut hole will be closed because of the ACA.
These cuts being proposed to the bundled dialysis rate was part of the Fiscal cliff deal in January. The savings that come from the duts are being spent on deficit reduction not on anyone's healthcare. Everything that happens in this world is not because of Obamacare and we aren't in much of a mess. Or at least I would say the mess is less than it has as been at any other time this century. Medicare has never been in better shape.
Dialysis has it's own problems. Problems with roots that go back to the seventies and the inception of the ESRD benefit. This particular cut, cuts care to what was being paid in 2011. Was care so terrible then? Was aaccess limited? The mistake the providers made in 2012 was to not bundle private payers when the Medicare bundle came in, most will make up the cuts by increasing charges to private payers. And the sky will not fall.
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... and as of next year the Part D Donut hole will be closed because of the ACA.
Actually, I think the Donut Hole will be closed in 2020.
8)
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I'm pretty sure they'll have to repeal Obamacare to get us out of this mess.
The money to pay for it is coming from ESRD patient care.
This isn't the case. Obamacare was paid for when the legislation passed
That is contrary to what I have been reading. There was no funding.
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Jeannea, Amen Sister!! But, as long as you have a pulse you are a money maker for these Dialysis Centers. Hamster on a wheel generating money. Sad but true.
Will these Dialysis Centers who make millions off sick people and Medicare really close their doors? We would start dropping dead after about a week. Are they really going to do this? I'm sure if they cut ALL Medicare they would close their doors and someone would step in but not in time. You know how fast Congress works.
Those on Home Dialysis better start hoarding supplies. The rest of us won't have a chance.
???
Actually, the two issues are quite related and intertwined. Those that opposed Obamacare to start with warned that Obama was going to raid Medicare and that cuts to the seniors would come shortly. The fact that we see these cuts beginning is not a surprise. Obama gutted Medicare to "pay" for the ACA.
http://www.breitbart.com/Big-Government/2013/02/20/With-Election-Over-Obama-Announces-Medicare-Cuts-To-Fund-ObamaCare
Completely ignorant. The problem with responding to reactionary folks like yourself is that you can post links from poorly written articles or politically slanted sites to claim the sky is falling very easily but it takes me a good amount of time to explain why your conclusions are wrong on a topic that is necessarily complex due to the nature of health care. I'll be responding when I have the time.
Those of you in the US worried about losing dialysis altogether, not going to happen. If there is any change in your level of care it will be due to the greed of the large providers to generate profits. As long as health care is a for profit industry without regulation this is always going to happen, Obamacare or otherwise. The money cut from Medicare was cutting the allowed rate of growth in future payments. Medicare payments rise a certain percentage each year, due to Obamacare Medicare growth was expected to decline in the rate of growth so the rate of growth in payments was cut to adjust for that. Incidentally, the Romney/Ryan plan for Medicare cut the same 700 billion that Obamacare cut. It was going to be gone one way or another.
The sky is not falling. Take the time to educate yourself on Obamacare before you fall for the fear, doom, and gloom that is being thrown about by these dialysis companies. This is a lot like Sarah Palin and her death panel nonsense. Lot of noise, little substance.
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While I would stress that HomeD is not a solution for every ESKD suffer, it should be part of the overall solution. The US and NZ in-center costs are not too dissimilar. In NZ the government promotes HomeD where it can because its better for the patient and the health budget. I believe you can get 4 HomeD for every one in-center.
As of 2011 33% of Hemo was HomeD in NZ. If the US pushed this more then there would be a significant cost savings that could ensure those that cant do HomeD would not loose hours or access to medications.
The US clearance target I believe is actually below NZ so it would be quite a negative to drop this further by reduced funding.
I'm not sure if NextStage is the right solution though. I have a Fresenius and its very very stable. Never had an issue in almost a year and have run it past its max operating time of 10 hours.
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Jeannea, Amen Sister!! But, as long as you have a pulse you are a money maker for these Dialysis Centers. Hamster on a wheel generating money. Sad but true.
Will these Dialysis Centers who make millions off sick people and Medicare really close their doors? We would start dropping dead after about a week. Are they really going to do this? I'm sure if they cut ALL Medicare they would close their doors and someone would step in but not in time. You know how fast Congress works.
Those on Home Dialysis better start hoarding supplies. The rest of us won't have a chance.
???
Actually, the two issues are quite related and intertwined. Those that opposed Obamacare to start with warned that Obama was going to raid Medicare and that cuts to the seniors would come shortly. The fact that we see these cuts beginning is not a surprise. Obama gutted Medicare to "pay" for the ACA.
http://www.breitbart.com/Big-Government/2013/02/20/With-Election-Over-Obama-Announces-Medicare-Cuts-To-Fund-ObamaCare
Completely ignorant. The problem with responding to reactionary folks like yourself is that you can post links from poorly written articles or politically slanted sites to claim the sky is falling very easily but it takes me a good amount of time to explain why your conclusions are wrong on a topic that is necessarily complex due to the nature of health care. I'll be responding when I have the time.
Those of you in the US worried about losing dialysis altogether, not going to happen. If there is any change in your level of care it will be due to the greed of the large providers to generate profits. As long as health care is a for profit industry without regulation this is always going to happen, Obamacare or otherwise. The money cut from Medicare was cutting the allowed rate of growth in future payments. Medicare payments rise a certain percentage each year, due to Obamacare Medicare growth was expected to decline in the rate of growth so the rate of growth in payments was cut to adjust for that. Incidentally, the Romney/Ryan plan for Medicare cut the same 700 billion that Obamacare cut. It was going to be gone one way or another.
The sky is not falling. Take the time to educate yourself on Obamacare before you fall for the fear, doom, and gloom that is being thrown about by these dialysis companies. This is a lot like Sarah Palin and her death panel nonsense. Lot of noise, little substance.
Dear Chris,
Let me make a few corrections to your post.
1) You state that the LDO's are not regulated. Sorry, look up the 2008 CFC's and read through the entire document. For your interest, even the regulators who do the Federal inspections complained that they were too complex and time consuming. Bill and I both participated in several conference calls and Bill attended a conference on this very issue on how to revise the inspection process. Note, this conference headed by a high level CMS official did not reduce the complexity of the 2008 CFC's for the LDO's. It simply addressed the difficulty the inspectors had in complying with the 2008 CFC's inspection requirements. So the regulators are saying they are too much to handle in a timely fashion, yet they did not reduce the requirements for the LDO's.
You may wish to read the regulations for yourself to make your own judgement on whether it is an "unregulated" industry.
http://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/downloads/esrdfinalrule0415.pdf
2) The oversight for the LDO's and all dialysis providers is "supposed" to be in large part through the ESRD networks. Unfortunately, they are only an extension of the LDO's and providers who fund these networks. True patient oversight is essentially lacking. CMS has not responded to multiple complaints at various levels on this incestuous relationship between the LDO's and the patient oversight process.
3) I am not at all reactionary my friend, just a fiscal conservative sadly watching our current government lead us into bankruptcy as a nation. Simply because you disagree with me does not in any manner make me ignorant or reactionary.
4) The Romney/Ryan plan had the medicare cuts in place because it is the law of the land as SCOTUS told us last summer. I guess you didn't read that they also promised to overturn and repeal Obamacare if elected.
5) Medicare payments to LDO's allegedly do not cover the full cost of treatments. LDO's make their most profit off of private insurance during the first 30 months of dialysis. If in fact, the medicare payments are lacking as many well respected folks contend, then indeed, a nearly 10% cut in Medicare reimbursement will have significant ramifications. In my opinion, it will not be their profit margins that suffer the most.
6) I have spent a great deal of time reading on Obamacare and my conclusion is that it will be an economic and health care disaster for this nation. Personally, Obama's tax policies pose a significant risk to my retirement and my healthcare I have through Kaiser. With the cuts that will occur with Medicare due to Obamacare and his tax policy, my own retirement plans will need to be completely revised. Thankfully, I still have 10 years before the biggest bite comes. Hopefully, I will be able to make the right changes to my plans now but that is not a reactionary or ignorant issue, it is my own personal reality and my wife's as well. In all seriousness, the taxes to my health care plan may force me to give it up altogether just to put food on the table at some point in time.
7) I have not yet written any posts on the Medicare cuts, but they will not be based on your alleged fear and gloom from the LDO's. Far from it. I am already quite well aware of the fear and doom that this nation's government controlled dialysis industry has wrought on hundreds of thousands of dialysis patients who suffered in units with the highest rate of death internationally. The untold torment of the last 40 years of the ESRD program where LDO's have made billions if not trillions of dollars from tax payers while producing the highest dialysis mortality and morbidity of any industrialized country is overlooked by those that should be ashamed and alarmed by this horrific medical performance in our dialysis units across this nation. Yes, congress and CMS has given a blind eye to these things for over 40 years while keeping a revolving door between the LDO's and the CMS regulators wide open.
Will the LDO's simply absorb these cuts without any reduction in services?? If you believe that will be the case, I have a bridge I would like to sell you.
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While I would stress that HomeD is not a solution for every ESKD suffer, it should be part of the overall solution. The US and NZ in-center costs are not too dissimilar. In NZ the government promotes HomeD where it can because its better for the patient and the health budget. I believe you can get 4 HomeD for every one in-center.
As of 2011 33% of Hemo was HomeD in NZ. If the US pushed this more then there would be a significant cost savings that could ensure those that cant do HomeD would not loose hours or access to medications.
The US clearance target I believe is actually below NZ so it would be quite a negative to drop this further by reduced funding.
I'm not sure if NextStage is the right solution though. I have a Fresenius and its very very stable. Never had an issue in almost a year and have run it past its max operating time of 10 hours.
Actually, the NxStage is an excellent platform with the advantage in my opinion over the current FMC machines. I cannot comment about the machines in development by FMC due to NDO but keeping to the Baby K for comparison, NxStage is a real contender for the leader in Home therapy. First, the NxStage has ultra-pure dialysate. Their Pureflow home system works well. The only complaint I had about the NxStage was low total dialysate. However, in April, the FDA approved an upgrade to the NxStage System One that will increase dialysate maximum flow rates by 50%, from 12 liters/hour to 18 liters/hour. The Baby K does not have ultra-pure dialysate which is a significant contributor of inflammation in dialysis patients.
The NxStage upgraded machine will produce 300 ml/min of dialysate flow which is still below the Baby K but a significant improvement over their prior settings I am looking forward to running 60 Liters in 4 hours instead of my current 40 Liters. I believe my clearances will approach those of a conventional in-center machine.
It takes me about 10 minutes to set up and about the same to clean and disinfect. The Baby K is a significant investment in time and effort. The NxStage is portable and the Baby K is not. When traveling, you can bring your own machine and NxStage will ship your supplies. When traveling with the Baby K, you must go in-center unless you are one of the rare patients to have a unit that offers NxStage for travel. The NxStage requires no RO system and no complex plumbing. With the increased dialysate flow rates which should offer significantly improved clearances, NxStage is well set to compete against FMC and the other corporations now and in the future in my opinion.
Lastly, the NxStage is a VERY reliable system with much less maintenance issues than the Baby K. If there is a problem, they will ship a new machine overnight. NxStage is truly an excellent choice for home dialysis therapy.
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My challenge with NextStage was 1) the number of complaints on this site and B) the sales rep in Australia that wasnt able to confirm the machine could match my current module for performance - I only wanted NextStage for holidays.
My machine runs for 10 hours every 2nd day. I'm asleep for most of that. Long hours and slow speeds increases clearance significantly over the shorter 4 hour sessions at higher speeds. I have charts to prove this, and most research backs it up.
I guess the day to day impact is zero complications for long hours verses crippling complications for short hours pretty much sealed my opinion of NextStage. The other issue was cost. They wanted 40k plus 20k per year for supplies. Thats more than the state pays for my current machine with no-where near the performance.
Not all people want to do long hours so NextStage will appeal to others.
I personally will never again dialysis for less than 8 hours. I have my life back, quite a bit of my energy, and whats the negative when I get cleaned while fast asleep.
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Also didn't know what Baby K was. Never heard of it. We use 4008B's in home and 5008 in-center. Parts of the country use Gambro but don't know which model.
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I'm pretty sure they'll have to repeal Obamacare to get us out of this mess.
The money to pay for it is coming from ESRD patient care.
This isn't the case. Obamacare was paid for when the legislation passed
That is contrary to what I have been reading. There was no funding.
I'd like to see the links to the analysis you've been reading but here is a PDF (http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/113xx/doc11307/reid_letter_hr3590.pdf) (http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/113xx/doc11307/reid_letter_hr3590.pdf (http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/113xx/doc11307/reid_letter_hr3590.pdf)) of the CBO analysis the summary statement is "CBO and JCT now estimate that, on balance, the direct spending and revenue effects of enacting H.R. 3590 as passed by the Senate would yield a net reduction in federal deficits of $118 billion over the 2010–2019 period."
And since it has now been the law of the land for a while you can check what the current federal deficit is and see if it has indeed gone down http://money.cnn.com/2013/05/07/news/economy/deficit-falling/index.html (http://money.cnn.com/2013/05/07/news/economy/deficit-falling/index.html)
"it estimated an annual deficit for 2013 of $845 billion, but some budget observers have said they expect the deficit for this year will come in lower than that."
so yes, as projected the deficit continues to go down
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Lastly, the NxStage is a VERY reliable system with much less maintenance issues than the Baby K. If there is a problem, they will ship a new machine overnight. NxStage is truly an excellent choice for home dialysis therapy.
Just to agree with Peter and say since the NxStage could make it down 400KM of the Colorado River through 125 rapids proves that it is very durable
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Lastly, the NxStage is a VERY reliable system with much less maintenance issues than the Baby K. If there is a problem, they will ship a new machine overnight. NxStage is truly an excellent choice for home dialysis therapy.
Just to agree with Peter and say since the NxStage could make it down 400KM of the Colorado River through 125 rapids proves that it is very durable
Yes, we always seem to agree on dialysis issues. Not so much on politics.
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I too am a BIG fan of NXSTAGE. I am a physician also . I run it for my wife 5 days per week. She feels so much better with the more frequent dialysis. Days off are hard on her. In center she felt terrible. now she walks on treadmill 25 minutes daily and SINGS.
The Nxstage system is SO easy to set up and run and clean up after. It is quick and simple. When i needed a new machine they had it out in under 24 hours ready to go.
The techs are there ALL the time as I have called them at 2;00AM once. They get on the line quickly anytime I call and during treatment even quicker. If ANYTHING goes wrong they talk me through it easily and clearly. I feel like they are in my house next to me.
The pureflow is great as it uses very little of my well water and the dialysate is great fertilizer for my fruit trees. i have the best PEE-CHES(peaches ) and apples ever this year.
The machine is quiet and I hardly have to touch it once it is running for the 3 hours of dialysis. The bags of dialyaste are great for emergencies or traveling. They are like a backup always there if I need them. I have NO complaints with Nxstage now. We have used it for over a year. Our machine feels like part of our family now. It gives us a lot and asks little in return.
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Fertilizer for your fruit trees? Ikkky!
:rofl;
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I personally don't have any complaints about NexStage, it just does not meet the minimum operating requirements required and is quite expensive for what to does.
I was quite intrigued however by the comment "they had a new machine out in 24 hours" and "the techs are there all the time". Probably need more context here, but the whole point of HomeD is that its independent and costs less. If a particular model needs constant replacement then it surly cannot be very robust. This also suggests the a huge amount of support is built into the 40k price I was quoted.
Someone is paying every time a tech shows up, and probably a lot more for 2am so I'm struggling to get the financial benefit of HomeD here. I think I have had 1 tech visit in 9 months for recalibration (+ their annual 3hr service), and I have not called the support team in over 7 months. that's 1,200 hours of treatment.
I live in a very small country where the state pays therefore efficiency and productivity is a key drive in keeping taxes down.
I guess I'm just saying that if the US is suggesting that funding may need to be reduced due to escalating costs then perhaps a focus should be on getting the best efficiency and productivity out of the process.
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I do agree that more context is needed. I used NxStage successfully for a year and a half on a 5x per week schedule and I credit it for allowing me to continually work a full time job while I was on dialysis, keep a home and still maintain a semblance of a social life. In the 18 months that I had the machine, I had to get one new machine and only called technical support a handful of times.
I always had good labs while I was using NxStage and was able to be more liberal with my diet.
Was my success with NxStage because I still urinated and never needed to remove much fluid (many times never removing anything but rinseback)? I don't know. All I know is I could no longer tolerate the long recovery times after harsh in center treatments and having to arrange my life around treatments was sending me down the depression spiral. NxStage changed all that and I am forever grateful to IHD which is where I found this modality, because it sure wasn't being advertised by my center.
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DaVita is threatening to close some urban and rural clinics that are most dependent on Medicare and Medicaid payments. Folks can discuss the merit of the cuts or not, but the threats I believe are quite real.
http://www.bizjournals.com/denver/news/2013/08/06/davita-warns-of-closing-clinics-due-to.html
In the context of the rest of medicine, many docs today refuse Medicare and Medicaid patients because of a simple fact. These government payments for healthcare do not cover in many cases even the overhead for a doctors visit. Medicine today is quite complex and doctors must have folks in their office who bill, collect, keep data bases, fix their computers, compliance officers to keep up with all of the Federal, state and local regulations in addition to all of the medical staff. When you consider the overhead costs of running a modern practice, there is good reason many of my colleagues have decided to avoid these government run programs. They simple cannot afford to do so with such minimal compensation.
Understanding these trends throughout medicine today, i don't for one minute believe that the threat to close clinics is at all an idle threat. There will be real consequences of the CMS cuts for one simple reason, the current payment system does not effect the market cost involved. It is an artificial payment in many ways even though yes, the prior system was quite abused by the industry especially with the separately billable items such as EPO.
Nevertheless, simply digging in and saying the LDO's deserve what is coming to them belies the message that it is not Kent Thiry who will suffer when the cuts hit nor will DaVita.
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DaVita is threatening to close some urban and rural clinics that are most dependent on Medicare and Medicaid payments. Folks can discuss the merit of the cuts or not, but the threats I believe are quite real.
http://www.bizjournals.com/denver/news/2013/08/06/davita-warns-of-closing-clinics-due-to.html (http://www.bizjournals.com/denver/news/2013/08/06/davita-warns-of-closing-clinics-due-to.html)
In the context of the rest of medicine, many docs today refuse Medicare and Medicaid patients because of a simple fact. These government payments for healthcare do not cover in many cases even the overhead for a doctors visit. Medicine today is quite complex and doctors must have folks in their office who bill, collect, keep data bases, fix their computers, compliance officers to keep up with all of the Federal, state and local regulations in addition to all of the medical staff. When you consider the overhead costs of running a modern practice, there is good reason many of my colleagues have decided to avoid these government run programs. They simple cannot afford to do so with such minimal compensation.
Understanding these trends throughout medicine today, i don't for one minute believe that the threat to close clinics is at all an idle threat. There will be real consequences of the CMS cuts for one simple reason, the current payment system does not effect the market cost involved. It is an artificial payment in many ways even though yes, the prior system was quite abused by the industry especially with the separately billable items such as EPO.
Nevertheless, simply digging in and saying the LDO's deserve what is coming to them belies the message that it is not Kent Thiry who will suffer when the cuts hit nor will DaVita.
Are they saying they can't sell the units? Because that would be a surprise that DaVita is operating a unit that is unsaleable at 2011 reimbursement rates. IIRC in 2011 units were being sold for over $70,000/patient.
This to me illustrates too big to regulate. The company that FMC grew out of - national medical? - extorted more money in the '80s when the composite rate was being established by threatening to close their units.
I haven't heard about many docs quitting Medicare, I've heard about the few who have started Concierge practices I wouldn't say that has been "many docs" by any standard. Medicaid is another issue and is very state dependent. It is true cuts to Medicare also cut reimbursement from dialyzors insured all or in part by Medicaid.
If DaVita has a unit in a state that is a poor Medicaid payer, and that unit's average reimbursement rate is below DaVita's costs then they should sell. I'll predict that these threatened units are in states that are the worst Medicaid payers ie states that pay nothing or very little of the 20% not paid by Medicare for people who are dual eligible and states who pay at or close to 80% of the Medicare allowed for those that Medicaid primary - for example South Carolina. Also units have been getting this extra money as hemoglobins have declined but for no longer than 2.5 years - are these units that dependent on this relatively new source of gravy that they have to be closed without it?
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I personally don't have any complaints about NexStage, it just does not meet the minimum operating requirements required and is quite expensive for what to does.
I was quite intrigued however by the comment "they had a new machine out in 24 hours" and "the techs are there all the time". Probably need more context here, but the whole point of HomeD is that its independent and costs less. If a particular model needs constant replacement then it surly cannot be very robust. This also suggests the a huge amount of support is built into the 40k price I was quoted.
Someone is paying every time a tech shows up, and probably a lot more for 2am so I'm struggling to get the financial benefit of HomeD here. I think I have had 1 tech visit in 9 months for recalibration (+ their annual 3hr service), and I have not called the support team in over 7 months. that's 1,200 hours of treatment.
I live in a very small country where the state pays therefore efficiency and productivity is a key drive in keeping taxes down.
I guess I'm just saying that if the US is suggesting that funding may need to be reduced due to escalating costs then perhaps a focus should be on getting the best efficiency and productivity out of the process.
The context is that there are 5,000+ units in use. Cost-wise the swap out maintenance model is the true business innovation of the device. I'm sure the total cost of a technician taking half a day or day to visit a far flung house is much greater than simply mailing a new device. My machine was swapped out when it reached 5,000 hours of use, a courier brought over the new one and packed up my old one - from the company's point of view think of the complexity that has been removed and their highly trained technicians stay hard at work chained to their desks.
Also Oz does speak an English of sorts, I'm sure you've talked to people for customer service that were located all over the world - NxStagers downunder may well be getting their tech support form the same US group as we do now - spreading efficiencies.
EDITED TO ADD: The cost savings are from fewer hospitalizations not less money spent providing dialysis.
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Bill, Medicare reimbursement rates have been under the cost overhead for quite some time. Many docs have left in the last few years and that trend is growing.
http://www.forbes.com/sites/brucejapsen/2013/01/01/27-pay-cut-or-not-more-docs-to-leave-medicare-in-2013/
As far as selling the units, who will buy? I would hope some of the non-profits could gain, but if the patient mix does not have enough private patients, the unit will have a hard time meeting their financial thresholds and cost overhead.
As far as what the reality of their finances truly is, no way to know that for certain. I am only relating that I doubt that the cuts will be passed to the share holders of FMC and DaVita. Instead, they will look to squeeze the patients once over again. I don't believe that these cuts will go with pain and suffering on patient's part much more so than the companies or their investors whether it is justifiable or not.
That puts advocates in a difficult spot. Advocate against the cuts, you contribute to LDO profiteering. Advocate for the cuts, it will certainly the patients that pay a large part of the cut. Once again, the LDO's are likely to gain more ground against the independents and SDO's more so than lose market share.
Yes, NMC operated in many unethical ways and that is how FMC was able to take over a much larger corporation that was facing severe fines and government penalties. It appears that the administration under Benn Lipps was much more responsive to date to patient needs than it appears it is today. I believe we both share a concern for further industry consolidation and the cuts in the end analysis will be much more damaging to the smaller dialysis providers that cannot operate on the economies of scale of DaVita and FMC.
That is the most likely outcome, but I suspect that DaVita especially will use this as an excuse to add further burdens to the patients. It leaves advocates in an uncomfortable position.
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As far as I am aware NZ does not subscribe to NextStage. There could be some private users but it was very expensive own and operate privately. On the basis HomeD was promoted to me as a long-hours option, I doubt any unit that that operates for less than 6 hours would be approved by the government for general use. My machine easily does 11 hour sessions while I'm asleep.
NZ is made up of 2 islands and I am of the understanding that in the South Island every hemo patient is HomeD. Across the whole country its 33% and new funding is approved for training centers not dialysis centers.
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I had to replace 1 Nxstage machine after over a year for a minor repair. They just swapped it out using a currier to switch. No big deal.
The techs NEVER come to house. I just call on phone with questions or any concerns. I tend to call when I want info but really have had few issues.
In the US we dont do enough home dialysis . In my area of Maine there are just 3 of us doing home hemo. I think a lot of people are scared to do it themselves.
The liquid dialysate is cleaner then manure for fertilizer. It does contain MUCH nitrogen and does make my whole place GREEN.
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And since it has now been the law of the land for a while you can check what the current federal deficit is and see if it has indeed gone down http://money.cnn.com/2013/05/07/news/economy/deficit-falling/index.html (http://money.cnn.com/2013/05/07/news/economy/deficit-falling/index.html)
"it estimated an annual deficit for 2013 of $845 billion, but some budget observers have said they expect the deficit for this year will come in lower than that."
so yes, as projected the deficit continues to go down
I misstated the projected deficit for 2013 by about 200 billion dollars. Sorry about that, I should have gone to the CBO for the most current numbers.
Here is the CBO's "Updated Budget Projections: Fiscal Years 2013 to 2023" http://www.cbo.gov/sites/default/files/cbofiles/attachments/44172-Baseline2.pdf (http://www.cbo.gov/sites/default/files/cbofiles/attachments/44172-Baseline2.pdf)
"If the current laws that govern federal taxes and spending do not change, the budget deficit will shrink this year to $642 billion, the Congressional Budget Office (CBO)
estimates, the smallest shortfall since 2008. Relative to the size of the economy, the deficit this year—at 4.0 percent of gross domestic product (GDP)—will be less than half as large as the shortfall in 2009, which was 10.1 percent of GDP. "
$642 Billion is a lot to me but it's not a trillion.
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Can that really be true that in NZ south island all hemo patients are at home? How does that work? If you can't handle doing it yourself do they send a nurse out? Or do they deny you care? It sounds impossible to me although an interesting dream.
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Can that really be true that in NZ south island all hemo patients are at home? How does that work? If you can't handle doing it yourself do they send a nurse out? Or do they deny you care? It sounds impossible to me although an interesting dream.
Perhaps that also includes PD?
8)
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Hi Zach, Good point. I was actually correct but there there is always devil in the detail. In NZ the health system is designed to catch potential ESRD long before dialysis is required. When this works and the patient falls under 15% dialysis workup is started. The choice of mode is then determined and PD plays a role here. If hemo is the choice then ability to be independent which includes using a family career is vital for most parts of the south island. This is because the area is vast and medical facilities only existing in the cities.
I am only aware of one private dialysis centre in my city mainly for inbound tourism, and only 3 public ones - I'm in the north island.
NZ and Australia are world leaders in HomeD and usually promote it when the patient is younger, cant do PD, or needs more treatment to sustain their lifestyle. Thus nocturnal is normally the solution. In my case 10 hours per session. Its well documented that the 3 days per week for 4 hours is very damaging and so where possible we go for the home option.
So not impossible and not a dream. The machines are easy to use, incredibly reliable and backed by a strong training program.
There will always be fringe cases and I imagine those individuals who cannot be independent would need to move the closest hospital. Its fair to say we do less well in the rest of the country but in the main city (Auckland) there is renewed investment in HomeD training centers.
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Remember too that there will be less complications when treatment is started @15% function verses 6%, so this may assist with the number of people suitable for homeD.
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As of 2010 http://www.kidneys.co.nz/resources/file/NZ%20Stds%20%20Audit%20Report%202010%20Final.pdf (http://www.kidneys.co.nz/resources/file/NZ%20Stds%20%20Audit%20Report%202010%20Final.pdf)
"The prevalent dialysis modality has changed little in recent years, with peritoneal dialysis (PD) usage ranging from 22% at Palmerston North to 53% at Waikato (national average 35%). Home haemodialysis usage ranges from 10% in Hawke’s Bay and Taranaki to 41% and 44% in Christchurch and Dunedin respectively (national average 18%)"
There look to be 15 units in the country (pop ~4 million).
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A couple of major misconceptions here.
Someone is paying every time a tech shows up, and probably a lot more for 2am so I'm struggling to get the financial benefit of HomeD here. I think I have had 1 tech visit in 9 months for recalibration (+ their annual 3hr service), and I have not called the support team in over 7 months. that's 1,200 hours of treatment.
The techs "there at 2AM" are on the phone.
I guess I'm just saying that if the US is suggesting that funding may need to be reduced due to escalating costs then perhaps a focus should be on getting the best efficiency and productivity out of the process.
That's not what the government is saying. The government is saying that care has already been cut by providers, therefore their reimbursement will be cut accordingly.
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DaVita is threatening to close some urban and rural clinics that are most dependent on Medicare and Medicaid payments.
Indeed, and this is called hostage-taking rhetoric. Or "Buy me that candy or I'll hold my breath until I die!!"
In the context of the rest of medicine, many docs today refuse Medicare and Medicaid patients because of a simple fact.
I hear this urban legend over and over and over. Where are the stats? What are the actual numbers?
I live in one of the most Medicare-heavy areas of the country, and I have yet to encounter a single doctor that won't take Medicare. In fact, most doctors advertise heavily and compete for Medicare patients. Why? Because when patients have Medicare, and doctors perform a procedure approved by Medicare, they KNOW THEY WILL BE PAID, and they pretty much know when.
This is ridiculously untrue of private "insurance". Every doctor whom I've had the opportunity to chat with about this has stories of cases where a procedure was performed and then an "insurance" company refused payment - because some picayune procedural detail, unique to that particular company and that particular policy, was not done correctly. I had one doctor tell me "Yeah, I put in a 12 hour day. Six hours seeing patients, and then six hours on the phone with insurance companies trying to get them to authorize payment for the treatment the patient needs."
And people always tell me that they've heard about doctors who won't take Medicare anymore - but no one has ever been able to actually name one that doesn't. I'm sure there are probably a few out there, somewhere. But consider this - where I've never encountered a doctor who doesn't take Medicare, I've encountered any number of doctors who said "Sorry, we don't take your insurance."
So which is the bigger issue?
These government payments for healthcare do not cover in many cases even the overhead for a doctors visit. Medicine today is quite complex and doctors must have folks in their office who bill, collect, keep data bases, fix their computers, compliance officers to keep up with all of the Federal, state and local regulations in addition to all of the medical staff. When you consider the overhead costs of running a modern practice, there is good reason many of my colleagues have decided to avoid these government run programs. They simple cannot afford to do so with such minimal compensation.
Yes. And the vast majority of extra employees with every doctor I know are insurance billing specialists. They have to have entire staffs whose only job is to try to keep up with the ever-shifting rules of private insurers.
There will be real consequences of the CMS cuts for one simple reason, the current payment system does not effect the market cost involved. It is an artificial payment in many ways even though yes, the prior system was quite abused by the industry especially with the separately billable items such as EPO.
Nevertheless, simply digging in and saying the LDO's deserve what is coming to them belies the message that it is not Kent Thiry who will suffer when the cuts hit nor will DaVita.
For the thousandth time - the cuts in patient care have already happened. The cuts in reimbursement are a response, not a cause.
I am constantly amused that people seem to believe that these huge corporations, who everyone admits are wholly driven by profit, have not already made all the cuts they can possibly make to increase their profit margins. Do they think the companies are that stupid and inefficient?
- rocker
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Dear Rocker,
Let's look at some of the specifics.
1) It is a well documented fact that the number of doctors who are refusing all Medicare is rising. In addition, for those that still accept Medicare, many are closed to new Medicare patients. As many as 20% of primary care docs will not accept new Medicare patients even though they continue to see their old patients with Medicare leading to great difficulty for new Medicare enrollees to find a primary care doc.
2) Medicare is heading for bankruptcy and large cuts loom over the docs every year to the tune of at least 25% threatened cuts that keep getting temporary reprieves. Many docs look on the inevitable fact that one day the cuts will take place and are making adjustments to their practice accordingly.
http://www.healthcarereforminsights.com/2012/11/28/medicares-2013-fee-schedule-compared-to-2012/
In fact, many are retiring early who remain in private practice because of the implementation of ACO's.
3) With ObamaCare, there will be a huge doctor shortage brought on by adding millions to the books while at the same time many as noted above are retiring early.
4) You are quite wrong about docs knowing that they will be paid with Medicare. A friend of mine who is a Family Physician in rural CA didn't get paid by Medicare for 18 months for services already rendered. Sorry, you are mistaken. Many procedures are disallowed and many only get a fraction of the going rate.
5) Many docs looking at the long term outcome of Medicare are moving to other more sustainable income possibilities. One of my friends from the world of Army medicine is now involved in a very lucrative concierge practice outside of Boston. That is just the reality of finances in medicine today. If you wish to remain in primary care and be an independent practitioner, doing so depending on Medicare is not a viable financial option especially when you consider the rate of indebtedness many of my colleagues have from medical school and add that to the costs of running an office.
Sorry, but your views of the medical community on Medicare are not the views I hear from within the physician community.
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Lastly, the topic at hand on cuts to medicare and loss of service I believe is more than just an idle threat from DaVita. It is interesting that the dialysis advocacy is greatly divided on this. Some contend that the industry is over paid and the cuts are justified and others are focussing on the potential harm to patient care.
I have no doubt that DaVita will dramatically shift to protect their own profits in a much more vigorous manner than they will devote time and effort to protecting individual dialysis patients. If you study their business philosophy, their "village" does NOT include the patients. Following this line of thought, who will they protect more, the folks "in" their "village" or the cogs in the wheels that are the dialysis patients when reimbursement falls by nearly 10%?
I have no doubt that the cuts will be passed on in a much greater fashion to the patients than to anyone in the DaVita village itself, although the lower fringes of the "village" are obviously expendable as well. Whatever you believe about the current reimbursement rates, the LDO's will shift their burden to the patient population. When Kent Thiry states he will shut down the centers with a high Medicare/Medicaid mix, why do you believe that is just smoke and mirrors? I suspect that is exactly what the consequences of a 9.4% cut in dialysis reimbursement will cause. In such a situation, people will die and suffer greatly especially in rural and inner city areas poorly served already.
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Dear Rocker,
Let's look at some of the specifics.
Specifically, that every complaint you make about Medicare is a problem that is orders of magnitude larger with private "insurance".
1) It is a well documented fact that the number of doctors who are refusing all Medicare is rising.
I can't seem to find your "documentation" of this. Is it in another thread, perhaps?
And as I point out above, whatever the number is, that number is overwhelmed by the number of doctors who will not take any given private insurance plan.
2) Medicare is heading for bankruptcy
Aren't we all, given the right set of circumstances?
3) With ObamaCare, there will be a huge doctor shortage brought on by adding millions to the books while at the same time many as noted above are retiring early.
And this......this just sickens me. This is the single most reprehensible argument against expanded coverage that I have seen.
Because to make this argument, you are saying that there are millions of American citizens who do not have access to a doctor right now - and that situation is preferable to having the insured perhaps wait a bit longer for an appointment. Who cares about the lives of millions of Americans - compared to your personal convenience?
4) You are quite wrong about docs knowing that they will be paid with Medicare. A friend of mine who is a Family Physician in rural CA didn't get paid by Medicare for 18 months for services already rendered. Sorry, you are mistaken. Many procedures are disallowed and many only get a fraction of the going rate.
Oh, I guess all of the doctors who have told me this are idiots. If only they knew "your friend."
And yes, of course many procedures are "disallowed". I don't want my tax dollars paying for snake oil, do you?
5) Many docs looking at the long term outcome of Medicare are moving to other more sustainable income possibilities.
And virtually every doctor has made the decision not to take any number of private policies.
Sorry, but your views of the medical community on Medicare are not the views I hear from within the physician community.
Why Pete, I can't imagine that we hang out with people who have differing opinions. How could that be?
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I have no doubt that DaVita will dramatically shift to protect their own profits in a much more vigorous manner than they will devote time and effort to protecting individual dialysis patients. If you study their business philosophy, their "village" does NOT include the patients. Following this line of thought, who will they protect more, the folks "in" their "village" or the cogs in the wheels that are the dialysis patients when reimbursement falls by nearly 10%?
I am baffled as to how you could think that this is not the current situation. This is always how they have behaved - and yet people are arguing that this behavior should be rewarded, lest they kill even more people.
I have no doubt that the cuts will be passed on in a much greater fashion to the patients than to anyone in the DaVita village itself, although the lower fringes of the "village" are obviously expendable as well. Whatever you believe about the current reimbursement rates, the LDO's will shift their burden to the patient population. When Kent Thiry states he will shut down the centers with a high Medicare/Medicaid mix, why do you believe that is just smoke and mirrors? I suspect that is exactly what the consequences of a 9.4% cut in dialysis reimbursement will cause. In such a situation, people will die and suffer greatly especially in rural and inner city areas poorly served already.
For the thousand and first time, the cuts in care have already happened. The reimbursement cut is because of that.
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Rocker, more than happy to give you quite a few links to back up my opinions. However, please show me that docs are happy with reimbursement rates with Medicare. Certainly there is fraud and abuse in the medical world, however do you even know what a primary care doc is paid for a full physical for a new Medicare patient?
Most docs have given up on pure private practice. When I got out of the Army in 1996, the recruiters didn't have a single private practice option available within the entire state of CA. Most docs are part of PPO's or some other insurance plan already. Pure private practice is becoming a very lonely venture with the exception of certain specialties where cash pay for services is expected.
As far as Medicare refusals by docs, finding that answer will only take you a few minutes of your time. Yes, it is well documented.
If you are unaware of the Medicare fiscal crises, not much sense having a debate on that issue with you.
For your information, dialysis companies make most of their profits off of private insurance, it is their preferred payor. In fact, many units "cherry pick" based on private insurance situations. If you believe that they prefer Medicare patients, I don't have much to say to you.
I retired from my renal disease thank you. Personal convenience had nothing to do with that decision. Failing to understand the doctor shortage that the ACA will exacerbate even more leaves me astounded you are unaware of this. Nevertheless, you diminish the fact that many docs are fed up with all of the regulatory changes making medicine a very difficult profession any longer. Would you like to learn a bit about physician burnout or just demonize my profession?
Sorry Rocker, your answers truly do not reflect the reality of practicing medicine in this nation.
ObamaCare is a huge disaster and a train wreck heading down the tracks. It is not likely that the GOP will overturn this unique American tragedy. 85-90% of people had "good" health care coverage prior to ObamaCare through their employers. Obama will certainly change the framework of our employer based health care. There are many who now have health care but their employers will choose to pay the IRS fine instead of paying much more for the ever rising health care premiums. In addition, are you aware that most of the new jobs in recent years are part time positions where no healthcare benefits are offered?
Although these folks will be able to go to the exchanges, many will earn "too much" to qualify for subsidies but not be able to afford the premiums even in the exchanges. on top of that, if you can't find a doc to take care of you, id doesn't matter how much insurance coverage you have. My friends at Kaiser are quite worried about how to care for the significant number of new patients the ACA will open up. The fact that you dismiss these real issues is quite astounding and leaves little room for any meaningful debate.
In any case, not likely I will change your extreme views but your reality is far from the reality of practicing medicine today.
Have a great day.
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Rocker, more than happy to give you quite a few links to back up my opinions.
Still waiting. However, links to opinion pieces with the same opinion as yours are not helpful. We all know people that share our opinion on a topic.
However, please show me that docs are happy with reimbursement rates with Medicare.
Show me anyone who thinks they are paid too much.
Most docs have given up on pure private practice.
This is an undeniable trend, and a sad indictment of corporate "medicine". I used to know a few doctors who had private practices - they have all, one by one, been acquired by large medical corporations seeking monopoly over care. When you have a monopoly over lifesaving care, people will pay whatever you ask or die.
As far as Medicare refusals by docs, finding that answer will only take you a few minutes of your time. Yes, it is well documented.
And yet again you sidestep the fact that this problem is many times larger for private insurance.
For your information, dialysis companies make most of their profits off of private insurance, it is their preferred payor. In fact, many units "cherry pick" based on private insurance situations. If you believe that they prefer Medicare patients, I don't have much to say to you.
I never said anything remotely like they "prefer" Medicare patients. We all prefer the customers who pay us the most. Whether we deserve it or not. That's hardly rocket science.
I retired from my renal disease thank you. Personal convenience had nothing to do with that decision. Failing to understand the doctor shortage that the ACA will exacerbate even more leaves me astounded you are unaware of this.
I suppose that I shouldn't be shocked that there are so many people that are callously dismissive of other human lives, but I still am a little. Or at least, that people are willing to be so open about it.
Granted, we wouldn't have gotten very far as a species without a survival instinct. But once you are surviving, many people's concern turns to helping others.
But obviously, not everyone's.
So I'm curious as to how you justify your life being so much more important than others', particularly given that you're retired?
Obama will certainly change the framework of our employer based health care. There are many who now have health care but their employers will choose to pay the IRS fine instead of paying much more for the ever rising health care premiums.
And where "But all that riffraff will want to see doctors now!" is the most disgusting argument against Obamacare, this is by far the most baffling.
I am an employer. I have never been compelled by any law to offer health insurance, and yet I did. Why is that? Was I just that stupid, to offer more than the law required?
I believe it had a lot more to do with the fact that in the jobs I offered, a number of benefits were considered standard offerings. A business simply could not attract quality employees without offering insurance. In addition, my employees were highly skilled, and not interchangeable. It would damage my business to have an employee out for an extended period of time, so it was in my best interest to see that they had access to good healthcare.
And, you know, I actually knew and cared about my employees and their families. But compassion doesn't appear to have a role in your worldview.
So all that said, what part of that changes so radically if there is now a punishment for not offering insurance?
Really, it's like saying that no one will drive over 60 if there are no speed limits, but if you set the speed limit to 70 suddenly everyone will drive at over 100mph just so they can pay the fines.
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Dear Rocker,
You are a bit bizarre my friend. Where have I ever stated my life is more precious than anyone else? Think what you may my friend, I grew up very modestly and I live very modestly. I was blessed with a wonderful career I worked very hard to attain that was cut short by renal disease as has happened to many. ObamaCare had nothing to do with my retirement. Not sure what absurd accusation you are trying but failing to make, but so be it. God is always good to me no matter the circumstances but you my friend are barking up the wrong tree.
There is no point in correcting your failed understanding of medicine and the practice of medicine. Because I disagree with Obamacare and the outrageous governmental intrusion into private matters you accuse me of a worldview without compassion. Wow. That is NOT how I practiced medicine for nearly 20 years as hundreds of my patients would testify to you, but to what end. Your accusations are silly and without any due justificatioin.
I have spoken quite a bit and written on the issue of health care and I do not in any manner represent the radical views you attribute to me. You mistakingly believe I support the for-profit dialysis corporations which couldn't be further from the truth. For your information, I support a non-profit health care system in the private sector. The Swedish model comes the closest to what I believe is the best system. ObamaCare does not come close to that model my friend.
Have a great day, we will just agree to disagree. Take care.
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Nephrology News & Issues
http://www.nephrologynews.com/articles/109681-davita-income-rises-35-in-second-quarter-of-2013
DaVita income rises 35% in second quarter of 2013
DaVita HealthCare Partners Inc. reported that income for the second quarter of 2013 rose almost 35% to $197.4 million, or $1.84 a share, compared to $146.7 million, or $1.53 a share, in the same quarter last year. Last year's results included the transaction expenses associated with the acquisition of HealthCare Partners Inc., and a legal settlement.
Operating income for the newly acquired HealthCare Partners segment of the business was $81 million, nearly $22 million less than the company guidance.
DaVita made 5,867,973, U.S. dialysis treatments in the second quarter of 2013, or 75,230 dialysis treatments per day, representing a per day increase of 7.6% over the second quarter of 2012. Non-acquired dialysis treatment growth was 5% over the same quarter last year.
# # #
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Nephrology News & Issues
http://www.nephrologynews.com/articles/109681-davita-income-rises-35-in-second-quarter-of-2013 (http://www.nephrologynews.com/articles/109681-davita-income-rises-35-in-second-quarter-of-2013)
DaVita income rises 35% in second quarter of 2013
DaVita HealthCare Partners Inc. reported that income for the second quarter of 2013 rose almost 35% to $197.4 million, or $1.84 a share, compared to $146.7 million, or $1.53 a share, in the same quarter last year. Last year's results included the transaction expenses associated with the acquisition of HealthCare Partners Inc., and a legal settlement.
Operating income for the newly acquired HealthCare Partners segment of the business was $81 million, nearly $22 million less than the company guidance.
DaVita made 5,867,973, U.S. dialysis treatments in the second quarter of 2013, or 75,230 dialysis treatments per day, representing a per day increase of 7.6% over the second quarter of 2012. Non-acquired dialysis treatment growth was 5% over the same quarter last year.
# # #
Interesting non acquired year on year growth was 5%, which is higher than overall growth - I'm hearing it is in the 3% range this year. The obvious business response to the bundle is to increase the number of treatments per dialyzor, it would be interesting to know the number of incneter treatments received by a patient starting and finishing the year using dialysis, I would guess that that number is increasing.
But the main thing is the EPO. As Rocker has pointed out, often, the service cuts have already occurred, less EPO is being delivered while the providers are being paid as if they were delivering the expected 5,200 units/treatment. DaVita is saving the expense of 3,000 units of EPO/per treatment while their reimbursement continues as if they're still delivering it, of course their profits are up.
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Looking at the advocacy around these cuts, most of it organized through KCP, I have to ask: Are they trying to keep the cuts in place?
I read nearly every comment to CMS on the proposed bundle and CMS's detailed response to those comments when they published the final rule. About half of the 1,200 or so comments were along the line - the bundle is bad. Don't bundle! Those comments had zero impact in improving the final rule. The final bundle rule was improved by engaging with CMS within the framework of the legislation.
You can make solid arguments against the rebalancing. You could say that the bundle is working, anemas are being managed with less EPO because the providers can direct resources to things like nursing: to for instance transition people from catheters. Or higher quality water to again decrease inflammation. And since inflammation decreases the impact of EPO, decreasing inflammation is better than just giving more EPO.
You could talk about the perversity of dialysis payments before the bundle and that this rebalancing is taking us back to the days when the composite rate was too lean and separately billable meds were supposed to make up the difference. The rebalancing as it is currently proposed will make the bundle a lean payment for the treatment and a lean payment for separately billable portion. It's the 2010 payment without the drug add on.
You could argue that since Medicare is fixing one problem with payment rebalancing they should also fix another - the leakage issue around comorbidities. Basically Medicare assumed there would be x number of people with comorbidities that add to the value of their bundled rate but after 2 years it is clear that the units are not finding all the people CMS says they should find. If CMS set aside an amount of money based on what the units have found vs what they think the units should find, it would add about $5 to value of the bundle.
I think you could also develop an argument that the bundle has resulted in a cost shift from private payers to Medicare - when the bundle went into effect EPO use among private payers fell too, but they weren't bundled so EPO revenue from private payers fell as well - now that that shift has happened units do not have the leverage to regain the lost revenue from the private payers. The bundle has made the providers more reliant on CMS thus CMS should be very thoughtful in their actions, and the incremental approach is called for, so I would recommend as a fall back position that the cut get implemented over time, for instance that the inflation adjustment be reduced by 1% for the next 10 years.
To me those are all arguments that have a chance of impacting the final rule. Saying this cut is bad and we'll close units if this cut goes through, has zero chance of impacting the final rule. If DaVita has to close units in SC and other bad Medicaid paying states, that's not really Medicare's problem so much as it is a problem for the voters in those states. Medicare will base its final rule based on the framework of the proposed rule which is based on the legislative language. I would have thought that the members of KCP would have used this time to put forward winning arguments rather than whining complaints.
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Dear Rocker,
Let's look at some of the specifics.
1) It is a well documented fact that the number of doctors who are refusing all Medicare is rising. In addition, for those that still accept Medicare, many are closed to new Medicare patients. As many as 20% of primary care docs will not accept new Medicare patients even though they continue to see their old patients with Medicare leading to great difficulty for new Medicare enrollees to find a primary care doc.
2) Medicare is heading for bankruptcy and large cuts loom over the docs every year to the tune of at least 25% threatened cuts that keep getting temporary reprieves. Many docs look on the inevitable fact that one day the cuts will take place and are making adjustments to their practice accordingly.
http://www.healthcarereforminsights.com/2012/11/28/medicares-2013-fee-schedule-compared-to-2012/
In fact, many are retiring early who remain in private practice because of the implementation of ACO's.
3) With ObamaCare, there will be a huge doctor shortage brought on by adding millions to the books while at the same time many as noted above are retiring early.
4) You are quite wrong about docs knowing that they will be paid with Medicare. A friend of mine who is a Family Physician in rural CA didn't get paid by Medicare for 18 months for services already rendered. Sorry, you are mistaken. Many procedures are disallowed and many only get a fraction of the going rate.
5) Many docs looking at the long term outcome of Medicare are moving to other more sustainable income possibilities. One of my friends from the world of Army medicine is now involved in a very lucrative concierge practice outside of Boston. That is just the reality of finances in medicine today. If you wish to remain in primary care and be an independent practitioner, doing so depending on Medicare is not a viable financial option especially when you consider the rate of indebtedness many of my colleagues have from medical school and add that to the costs of running an office.
Sorry, but your views of the medical community on Medicare are not the views I hear from within the physician community.
Good post, as a trained Economist, we agree.
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Rocker, more than happy to give you quite a few links to back up my opinions.
Still waiting. However, links to opinion pieces with the same opinion as yours are not helpful. We all know people that share our opinion on a topic.
However, please show me that docs are happy with reimbursement rates with Medicare.
Show me anyone who thinks they are paid too much.
Most docs have given up on pure private practice.
This is an undeniable trend, and a sad indictment of corporate "medicine". I used to know a few doctors who had private practices - they have all, one by one, been acquired by large medical corporations seeking monopoly over care. When you have a monopoly over lifesaving care, people will pay whatever you ask or die.
As far as Medicare refusals by docs, finding that answer will only take you a few minutes of your time. Yes, it is well documented.
And yet again you sidestep the fact that this problem is many times larger for private insurance.
For your information, dialysis companies make most of their profits off of private insurance, it is their preferred payor. In fact, many units "cherry pick" based on private insurance situations. If you believe that they prefer Medicare patients, I don't have much to say to you.
I never said anything remotely like they "prefer" Medicare patients. We all prefer the customers who pay us the most. Whether we deserve it or not. That's hardly rocket science.
I retired from my renal disease thank you. Personal convenience had nothing to do with that decision. Failing to understand the doctor shortage that the ACA will exacerbate even more leaves me astounded you are unaware of this.
I suppose that I shouldn't be shocked that there are so many people that are callously dismissive of other human lives, but I still am a little. Or at least, that people are willing to be so open about it.
Granted, we wouldn't have gotten very far as a species without a survival instinct. But once you are surviving, many people's concern turns to helping others.
But obviously, not everyone's.
So I'm curious as to how you justify your life being so much more important than others', particularly given that you're retired?
Obama will certainly change the framework of our employer based health care. There are many who now have health care but their employers will choose to pay the IRS fine instead of paying much more for the ever rising health care premiums.
And where "But all that riffraff will want to see doctors now!" is the most disgusting argument against Obamacare, this is by far the most baffling.
I am an employer. I have never been compelled by any law to offer health insurance, and yet I did. Why is that? Was I just that stupid, to offer more than the law required?
I believe it had a lot more to do with the fact that in the jobs I offered, a number of benefits were considered standard offerings. A business simply could not attract quality employees without offering insurance. In addition, my employees were highly skilled, and not interchangeable. It would damage my business to have an employee out for an extended period of time, so it was in my best interest to see that they had access to good healthcare.
And, you know, I actually knew and cared about my employees and their families. But compassion doesn't appear to have a role in your worldview.
So all that said, what part of that changes so radically if there is now a punishment for not offering insurance?
Really, it's like saying that no one will drive over 60 if there are no speed limits, but if you set the speed limit to 70 suddenly everyone will drive at over 100mph just so they can pay the fines.
Rocker, HemoDoc has never, ever supported For-Profit Dialysis companies. In fact, we have argued on many issues over the years on different boards. I was with Davita for five years. If you think Kent Thiry would not protect his wallet over a dialysis patient, you are drunk and have been drinking. Davita DOES NOT have compassion for any dialysis patient. If you believe that, you are nuts. HemoDoc has been very, very critical of the dialysis industry and rightly so...... As a trained Economist, what Obama is telling you is a big fat lie. I have been on Home Dialysis for seven years and I am a former police officer. So, if you think I am easily frightened, you would be extremely misguided. I argued with Davita, day and night, and twice on Sundays. In fact, it was just one loud arguement. Yes, I have been in management, just like you. Look at the numbers, do you think the employer is going to pay a fine of $2,000 or health insurance costs that are thousands upon thousands of dollars? Many employees are not highly skilled, not like the majority of people in your company, that is not reality. What happens to a business who pays an employee much more than that employee produces??? The company goes out of business. What Obama is doing is not compassion, he cares more about how he thinks of himself, that the actual reality of what he is doing to people on dialysis and the average individual. I hate to inform you that most law school grads, like Obama, have little to no knowledge about Basic Economics. Yes, I am in law and I was an Economics major. Obama also knows nothing about science, most of my family is in the hard sciences, Chemistry and Physics. Obama bashes certain groups, because it wins votes, it is just that simple. In fact, one of Obama's advisors was a board member at Davita and cashed in, making millions of dollars, was Obama's advisor compassionate?
"President Obama’s health-care czar and deputy chief of staff, Nancy-Ann DeParle, made more than $2 million in compensation and stock sales as a DaVita board member from 2002 to 2008."
http://www.5280.com/magazine/2012/09...earth?page=0,4
WASHINGTON—President Obama has named former DaVita director Nancy-Ann DeParle to be the nation’s health czar, who will coordinate the administration’s health policy.
DeParle, 52, will serve as counselor to the president and director of the White House Office for Health Reform. Her position is not subject to Senate confirmation.
Obama made the announcement after he nominated Kansas Gov. Kathleen Sebelius to be the secretary of health and human services. Tom Daschle was originally pegged to fill both roles, but had to bow out after he revealed that he owed more than $140,000 in back taxes.
At a White House news briefing, Obama’s press secretary Robert Gibbs said DeParle will “head health care reform here in the White House.”
DeParle became a director for dialysis provider DaVita 2001. She has also served on the boards of Boston Scientific Corp., Cerner Corp. and Medco Health Solutions. DeParle was also a senior advisor to private-equity firm JPMorgan Partners and an adjunct professor at the WhartonSchool of the University of Pennsylvania.
She was appointed Tennessee Commissioner of Human Services in 1987 at age 30 and oversaw 6,000 agency employees that provided adult rehabilitation services, food stamps, child welfare and cash assistance.
Between 1993 and 1997, DeParle was the Associate Director of the White House Office of Management and Budget. And in 1997, President Clinton appointed her as the Administrator of the Health Care Financing Administration, which is now the Centers for Medicare & Medicaid Services.
She has also served as a member of the Medicare Payment Advisory Commission, which advises Congress on Medicare payment policy.
http://www.renalbusiness.com/news/2009/03/obama-names-former-davita-director-health-czar.aspx
Hey Rocker, who do you think is going to benefit from this appoinment, do you think it will be dialysis patients????
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Rocker, HemoDoc has never, ever supported For-Profit Dialysis companies.
I don't understand how this is in any way related to this thread, nor how you imagine that I thought that.
He has, however, argued against the cuts, and takes their hostage rhetoric seriously. I am for the cuts, and think their rhetoric is bull.
If you think Kent Thiry would not protect his wallet over a dialysis patient, you are drunk and have been drinking. Davita DOES NOT have compassion for any dialysis patient. If you believe that, you are nuts.
Since I have said more or less exactly that, I'm not sure what you're arguing...?
Yes, I have been in management, just like you.
I didn't say I was "in management". My husband and I own a business. We are those "small businesspeople" that politicians like to pretend they're pandering to. But the "concerns" politicians claim we have are generally not remotely close to reality.
Look at the numbers, do you think the employer is going to pay a fine of $2,000 or health insurance costs that are thousands upon thousands of dollars? Many employees are not highly skilled, not like the majority of people in your company, that is not reality.
Right, that's not what HD said. Of course the McD's and WMs are going to do that - they don't care about their employees.
What in fact HD said was that companies that now provide insurance (NOT WM and McD's, but companies that care about employees) would stop doing that and pay the fine instead.
Which is ludicrous.
What happens to a business who pays an employee much more than that employee produces???
This is, ummmm, kind of a silly question. If an employee is not doing the work they were hired to do, they are fired. If, however, your business model is so bad that no employee can produce enough to cover their costs - then you have a deeply flawed business model and will quickly fail regardless of law.
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I guess, Rocker, that you will not like hearing this but, I have been invited to go to Washington DC as part of an advocacy group to argue AGAINST the proposed cuts to the ESRD program. And, Yes, I am going!
Anyone who thinks that it will only be ESRD effected is in for a huge surprise. No, it will only START with the ESRD program...
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I guess, Rocker, that you will not like hearing this but, I have been invited to go to Washington DC as part of an advocacy group to argue AGAINST the proposed cuts to the ESRD program. And, Yes, I am going!
Anyone who thinks that it will only be ESRD effected is in for a huge surprise. No, it will only START with the ESRD program...
I don't begrudge anyone their opinion. I advocate for my own, and give the reasons why. I hope your trip is pleasant, and that your opinion is heard. I do love DC - so many beautiful museums and public spaces. Hope you have time for some sightseeing!
This is a complex issue, and cannot be boiled down into a few posts on a message board.
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[quote author=NDXUFan link=topic=29264.msg464816#msg464816 date=1376476489
What Obama is doing is not compassion, he cares more about how he thinks of himself, that the actual reality of what he is doing to people on dialysis and the average individual. I hate to inform you that most law school grads, like Obama, have little to no knowledge about Basic Economics. Yes, I am in law and I was an Economics major. Obama also knows nothing about science, most of my family is in the hard sciences, Chemistry and Physics. Obama bashes certain groups, because it wins votes, it is just that simple. [/quote]
These are the kinds of sweeping statements that make people tune out. You do your arguments no favors when you indulge in this sort of rhetoric. No president knows everything about every subject, which is why they have advisors.
I doubt the President "cares more about how he thinks of himself", but it is probably true that he, like every other politician in Washington, cares too much about the health insurance industry and other corporate interests. Unfortunately, he has to put forward ideas and legislation that will actually get through Congress. So, to get a more accurate view, I suggest that in your post, replace "Obama" with "Congress".
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This may be a simple question regarding a complex subject, but it seems to me that most politicians are telling us that entitlements need to be cut. So, why are any of you surprised and/or outraged that cuts will be made to the ESRD program? It's an "entitlement", isn't it? Aren't there a lot of people out there telling us that government shouldn't be involved in our health care? And don't a lot of people vote for these politicians who run on this sort of platform?
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Rocker, HemoDoc has never, ever supported For-Profit Dialysis companies.
I don't understand how this is in any way related to this thread, nor how you imagine that I thought that.
He has, however, argued against the cuts, and takes their hostage rhetoric seriously. I am for the cuts, and think their rhetoric is bull.
Actually, you are quite wrong once again Rocker. I have not yet taken a formal position on the cuts. When I do, I will write a post on my blog. I have voiced concern that the threatened shut down of clinics by DaVita is likely not an idle threat and that the 9.4% cut will passed to the patients, not the share holders. That is my opinion of how DaVita and the other LDO's will likely respond to protect their profits which is their motivation for staying in this business.
That places advocacy in a very divided position where we have no doubt that the greed and profiteering of these companies is out of control and at the same time that the burden of these cuts will be placed on the backs of the patients even further than they are now.
Yes, the dialysis industry does hold a dagger to our throats in their threats, but as history would tell us, the game that they have played will result in further pain, suffering and misery for an untold number of patient as they have done for over 40 years already. Just as Obama is intentionally making the sequester cuts hurt as much as possible to gain political advantage over the GOP (even though the sequester was his idea), so likewise do I believe that LDO's will do the same.
So what is the correct response to the cuts. 1) support the cuts and risk the outrage when DaVita and other LDO's follow through with their threats or 2) oppose the cuts and support the greed and profiteering of the LDO's. What my friend is the right path that will unite dialysis patients, that will protect dialysis patients and that will improve care for dialysis patients in America?
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This may be a simple question regarding a complex subject, but it seems to me that most politicians are telling us that entitlements need to be cut. So, why are any of you surprised and/or outraged that cuts will be made to the ESRD program? It's an "entitlement", isn't it? Aren't there a lot of people out there telling us that government shouldn't be involved in our health care? And don't a lot of people vote for these politicians who run on this sort of platform?
As nearly as I can tell, MM, the definition of "entitlement" that they use is "anything that does not directly benefit me."
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As nearly as I can tell, MM, the definition of "entitlement" that they use is "anything that does not directly benefit me."
Ya think? I'm just baffled.
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I just want to say with this whole argument about doctors denying patients and not being paid, be careful not to confuse Medicare and Medicaid. You will find statistics for both but it's easy to see something like "25% of doctors refusing patients" and see the Medi part and just assume. Some changes are happening to Medicare and some to Medicaid.
Unfortunately, in a general way nothing will change. The system has a lot of flaws now and it will have a lot of flaws later. For some people things will get better. For some people things will get worse. For some people it will be pretty much the same. Being on dialysis sucks and will continue to suck.
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I just want to say with this whole argument about doctors denying patients and not being paid, be careful not to confuse Medicare and Medicaid. You will find statistics for both but it's easy to see something like "25% of doctors refusing patients" and see the Medi part and just assume. Some changes are happening to Medicare and some to Medicaid.
Unfortunately, in a general way nothing will change. The system has a lot of flaws now and it will have a lot of flaws later. For some people things will get better. For some people things will get worse. For some people it will be pretty much the same. Being on dialysis sucks and will continue to suck.
True. Medicaid plays a big role in it in another way - a lot depends on whether a state pays the 20% not covered by Medicare for people who qualify for both Medicare and Medicaid. For people using dialysis about 50% of the people that have Medicare as their primary insurance have Medicaid as their secondary. Right now, according to my info, 21 states Medicaid does not pay or pays a small portion of the 20%. For docs reluctance to accept Medicare patients it is largely due to a judgement about their secondary insurance. If they're in a state with Medicaid that does not pay secondary to Medicare then they have to think if getting paid 80% of Medicare allowed rate is going to work for their business.
Our system leaves the states with the job of setting Medicaid policy. If that's the policies the people of Texas and Florida wish to live with then that is their right. Medicare shouldn't have to increase their reimbursement for the whole country to make up for the states with low Medicaid reimbursement.
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Rocker, HemoDoc has never, ever supported For-Profit Dialysis companies.
I don't understand how this is in any way related to this thread, nor how you imagine that I thought that.
He has, however, argued against the cuts, and takes their hostage rhetoric seriously. I am for the cuts, and think their rhetoric is bull.
If you think Kent Thiry would not protect his wallet over a dialysis patient, you are drunk and have been drinking. Davita DOES NOT have compassion for any dialysis patient. If you believe that, you are nuts.
Since I have said more or less exactly that, I'm not sure what you're arguing...?
Yes, I have been in management, just like you.
I didn't say I was "in management". My husband and I own a business. We are those "small businesspeople" that politicians like to pretend they're pandering to. But the "concerns" politicians claim we have are generally not remotely close to reality.
Look at the numbers, do you think the employer is going to pay a fine of $2,000 or health insurance costs that are thousands upon thousands of dollars? Many employees are not highly skilled, not like the majority of people in your company, that is not reality.
Right, that's not what HD said. Of course the McD's and WMs are going to do that - they don't care about their employees.
What in fact HD said was that companies that now provide insurance (NOT WM and McD's, but companies that care about employees) would stop doing that and pay the fine instead.
Which is ludicrous.
What happens to a business who pays an employee much more than that employee produces???
This is, ummmm, kind of a silly question. If an employee is not doing the work they were hired to do, they are fired. If, however, your business model is so bad that no employee can produce enough to cover their costs - then you have a deeply flawed business model and will quickly fail regardless of law.
Firing employees is a very expensive proposal, as I have been told by a number of CEO's, mostly small business people. Many small business people are opposed to ObamaCare, especially employers who are offering health insurance to their employees......
Jancoa CEO Mary Miller testified on the impact of Obamacare:
Staff
Cincinnati Business CourierJancoa Janitorial Services CEO Mary Miller testified this week for the Committee on Oversight & Government Reform on the economic and job creation impact of Obamacare.
The health care law’s employer mandate will force the Cincinnati-based company to either increase premiums, cease employee coverage and pay a penalty, or downgrade workers from full-time to part-time, Miller said.
“The law will force my husband and me to choose between several impossible options in order to remain in business,” Miller said in her statement to the committee. “This will jeopardize our ability to offer jobs that employees value.”
The commercial cleaning company has 320 full-time employees. Miller also will be featured on the “Willis Report” on Fox Business channel this evening at 6 p.m. to further discuss the issue
http://www.bizjournals.com/cincinnati/news/2012/07/11/jancoa-ceo-mary-miller-testified-on.html
Yes, I do live in Cincinnati and I am aware of the company. No, they do not have margins to afford Obamacare. They will have to pay either $684,000 in fines or $1.5 million in increased health insurance costs. The company simply does not have the margins to afford this expense. As Obamacare pushes these companies out of business, this will mean less tax revenue for dialysis, not a really smart idea, is it?
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[quote author=NDXUFan link=topic=29264.msg464816#msg464816 date=1376476489
What Obama is doing is not compassion, he cares more about how he thinks of himself, that the actual reality of what he is doing to people on dialysis and the average individual. I hate to inform you that most law school grads, like Obama, have little to no knowledge about Basic Economics. Yes, I am in law and I was an Economics major. Obama also knows nothing about science, most of my family is in the hard sciences, Chemistry and Physics. Obama bashes certain groups, because it wins votes, it is just that simple.
These are the kinds of sweeping statements that make people tune out. You do your arguments no favors when you indulge in this sort of rhetoric. No president knows everything about every subject, which is why they have advisors.
I doubt the President "cares more about how he thinks of himself", but it is probably true that he, like every other politician in Washington, cares too much about the health insurance industry and other corporate interests. Unfortunately, he has to put forward ideas and legislation that will actually get through Congress. So, to get a more accurate view, I suggest that in your post, replace "Obama" with "Congress".
[/quote]
As you are probably aware, I am not a fan of Davita and "Millions" Thiry. I do not care about the health insurance industry, nothing, zip, and zero. Politicians protect the health insurance industry by not allowing individuals to buy health insurance across state lines, in other words, it is a health insurance monopoly, this is one of the main reasons that health insurance prices are so outrageous. Think of how cable acted without the satellite dish industry or MaBell acted without competition, remember? Obama likes to dictate, not work with......
By the way, here are some comments from an elected Democrat:
Whatever happened to the rule of law? If he gets to write his own laws and decide which ones he will ignore, when do we get the chance to decide which laws we will follow and which we won't? Sound likes anarchy to me.
https://www.facebook.com/dusty.rhodes.731?fref=ts&ref=br_tf
From the Liberal Washington Post:
Can Obama Write His Own Laws?
"Which followed hundreds of Obamacare waivers granted by Health and Human Services Secretary Kathleen Sebelius to selected businesses, unions and other well-lobbied, very special interests."
You want to talk about special interests???
http://www.washingtonpost.com/opinions/charles-krauthammer-can-obama-write-his-own-laws/2013/08/15/81920842-05df-11e3-9259-e2aafe5a5f84_story.html
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This may be a simple question regarding a complex subject, but it seems to me that most politicians are telling us that entitlements need to be cut. So, why are any of you surprised and/or outraged that cuts will be made to the ESRD program? It's an "entitlement", isn't it? Aren't there a lot of people out there telling us that government shouldn't be involved in our health care? And don't a lot of people vote for these politicians who run on this sort of platform?
Yes, it is correct that entitlements need to be cut. You are right, government should not be involved in our health care, because it greatly increases the cost to the patient or health care consumer. For example, in a health insurance policy for a family, there are around 2,000 mandates from government, this makes the health care policy unaffordable to most working and middle class families. In addition, this drives the cost of a office visit to the physician from $20.00 to $100.00, because the physician or physician's group has to hire so many people to keep up with government and private insurance regulations. A high deductible policy is much, much more economical for the vast majority of people. Yes, I realize that is too expensive for some individuals and families, therefore, eliminating government mandates will drive down costs to those folks. The government pays for 45 percent of all medical bills in the United States, meaning our health care system is not a truly free market system. There are many problems with our health care system, mainly, a lack of competition in hospitals and physicians, this greatly increases cost to individuals and families. One of the reasons dialysis is so expensive, is a lack of competition, mainly just two providers, DaVita and Fresenius....... How has that worked for the dialysis patient? Costs are generally excessive when there is no competition, think of the cable and phone companies, years ago. Remember, paying $.10 per minute for a long distance phone call?
Health care is a business and we need to start realizing that to protect our wallets. It is a business, not a charity. The way to protect our wallets is to introduce these people to competition..... If you dislike what the XYZ grocery store charges or the quality of their products, you leave them and go to the ABC grocery store..... If any group of people need the protection of competition, it is dialysis patients. Trust me, Old "Millions" Thiry would protect his wallet, he is never interested in protecting your wallet or that of the working and middle class taxpayer.
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Does anyone on here really believe that "Millions" Thiry is worth his yearly compensation? Do you think Davita is really worth billions per year? Competition and choosing other providers is the way to register our disapproval of "Millions" and his crappy dialysis care.
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Firing employees is a very expensive proposal, as I have been told by a number of CEO's, mostly small business people.
Expensive....how? Why? The only "cost" I'm aware of related to firing is the cost of hiring and training a new employee to replace the lost worker. But that's the same regardless of whether they are fired, or quit.
Many small business people are opposed to ObamaCare, especially employers who are offering health insurance to their employees......
Yes, many small business people are opposed to all kinds of laws. However, small businesses have little reason to oppose Obamacare - as the employer mandates do not apply to businesses with fewer than 50 employees.
[story about a cleaning business]
Yes, I do live in Cincinnati and I am aware of the company. No, they do not have margins to afford Obamacare. They will have to pay either $684,000 in fines or $1.5 million in increased health insurance costs. The company simply does not have the margins to afford this expense. As Obamacare pushes these companies out of business, this will mean less tax revenue for dialysis, not a really smart idea, is it?
First of all, 320 employees is much larger than "small business". A small business is generally considered to be one with fewer than 50 employees.
From the story, it appears that what they offer employees is nothing resembling "insurance" if they are worried about Obamacare "mandates". (Like, a limit on OOP costs.) You can easily buy "insurance" policies around here that advertise that they cover "up to $1000 if you are hospitalized!" I think we all know that $1000 won't even get your blood pressure checked.
Roughly three-quarters of bankruptcies in the US are caused by medical expenses - of those, roughly two-thirds of the people had insurance at the time their expenses were incurred. There is a lot of worthless crap calling itself "insurance" in the US. Of what possible use is a high-deductible (say, $10,000) policy to someone making $400 a week? In my experience, unless it's an emergency, doctors will demand payment up front from people with policies like that.
The annual employer penalty is, IIRC, around $2000 per full-time employee. If this business owner is complaining about the huge new expense the penalties will cause them - well, what kind of "insurance" do you suppose you can get for less than $2000 per year?
Also, didn't you claim to be an economist? Are you suggesting that this company's customers will simply forego cleaning services, and thus that revenue will be lost? Doesn't the market model suggest that if this business fails, another one will take its place to fill the need? So how is that tax revenue "lost"?
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Smoke and mirrors: What is really behind protests over the ESRD bundle payment cut?
http://www.nephrologynews.com/blogs/5-guest-blog/post/109706-smoke-and-mirrors-what-is-really-behind-protests-over-the-esrd-bundle-payment-cut
Nephrology News & Issues
Richard Berkowitz August 23, 2013
As a home dialysis patient, I visit my clinic every month to see my nephrologist and care team. I had such a visit last week and before I left, my social worker came to see me. After we talked, she put a letter in front of me and asked me if I would sign it.
It was entitled “Protect dialysis treatments,” and was obviously a letter intended for Congressional representatives, although it did not list them by name. Essentially, it said that I rely on dialysis to remain alive and that the proposed 12% cut by the Centers for Medicare & Medicaid Services to the ESRD bundled payment would threaten my ability to receive my treatment. After saying I wouldn’t sign it, I was asked if I was absolutely sure. I said I was.
It’s amazing what the renal provider community can do when they put their minds to it. In this case, it is about protecting money—their money. This effort to get patients involved in a letter writing campaign—hundreds of these form letters have already been sent to Congress with the help of the provider community—has to do more with the bottom line than patient care. Patients should not be used as pawns in a series of scare tactics to protest a change in a payment dispute between a payer and a provider of services. The industry relies heavily on Medicare to operate its clinics, but that’s no excuse to leverage its position by hiding behind dialysis patient chairs and using us to stop a pay cut. In my view, it is unconscionable.
“We were alarmed…”
Astute chief financial officers of dialysis companies large and small must have known this day was coming. CMS’ proposed 12% cut in the ESRD bundled payment rate––actually, a 9.4% reduction after CMS added in a 2.6% increase after its annual market basket review of operational costs––is not based on an arbitrary review. The Medicare Improvements for Patients and Providers Act of 2008 instructed CMS to use 2007 data to build the ESRD bundled payment model, so the agency did what it was told to do. That was the most complete data available at the time.
Being pre-bundle, ESAs were still separately billable and profitable for dialysis clinics. The damaging CHOIR and CREATE studies were published in late 2006, but the debate over the results stalled any real change in dosing patterns. And the FDA black box warning changes issued in March 2007 about minimizing the use of ESAs did not lead to a major drop in dose, according to a recent study.1 So, as a baseline year to determine payment for ESA use, 2007 was a positive for providers dealing with the bundle––particularly if CMS didn’t make any subsequent updates.
The proposed 12% cut came about after a Government Accountability Office report, released in December of last year, questioned whether CMS should have been doing exactly that: making adjustments to the injectable drug payment as dialysis clinics started ratcheting down ESA doses shortly after the bundle took effect. In essence, CMS was paying clinics for using high doses of ESAs at the same time as providers were cutting back use of the drug to save money.
That, said the GAO, cost Medicare between $660–$880 million in excess payments. “Although MIPPA did not explicitly authorize CMS to further recalculate this rate—referred to as rebasing the payment rate—to account for changes over time in the utilization of dialysis and related items and services, such as ESRD drugs, beginning in 2012 CMS [was] required to annually increase the bundled payment amount to account for changes in the prices of bundled items and services and for changes in productivity.”
And CMS did make adjustments for changes in productivity, giving dialysis providers an increase in the base rate over the last two years: 2.1% in 2012, and 2.3% in 2013, and, as proposed, a 2.6% increase for 2014.
So as of today, here is the scenario I see:
... CMS is paying dialysis providers for injectable drugs (GAO says 73% of that is ESA use) based on much higher dosing patterns from 2007, as they were instructed to do by Congress.
... Dialysis providers have collected those payments for the last 2 ˝ years, while ratcheting down ESA use. Among patients receiving intravenous epoetin, mean prescribed dose has decreased by 33% since the bundled payment system was put in place in January 2011, according to data from the Dialysis Outcomes Practice Patterns Study’s Dialysis Practice Monitor.
... Dialysis providers have been issued two increases to the base composite rate, and a third is on its way for 2014.
... So Congress, in a twisted way, perpetuated use of ESAs as a “profit center” for dialysis clinics within the bundle, and CMS added fuel to the flames by not adjusting the payment. And now, the renal community has been able to get patients and 200 members of Congress––who approved the American Taxpayer Relief Act of 2012 authorizing CMS to make a payment cut in the first place––to criticize the agency for the size of the reduction.
That’s called good lobbying.
If CMS had taken action at the end of 2011 and 2012 to adjust the injectable drug component of the bundled payment model, which MIPPA gave them the authority to do, and still offer the market basket-based increases to the base rate, we might not be hearing providers screaming today about closing dialysis clinics and the ESA payment rate would reflect the true utilization by providers.
Where has all that money gone?
Despite those extra dollars funneled down to dialysis providers, many still complain of thin profit margins. Some of that money, they say, has helped to pay for unfunded mandates, like implementing CROWNWeb and its myriad reporting requirements, and for collecting data for the Quality Incentive Program. The recent 5% increase in the cost of Epogen has also had an impact. Those costs are real, especially for the small independent providers and medium-sized dialysis organizations.
But is that worth putting patient faces on ads and threatening to shut down clinics—before even sitting down with CMS to negotiate a compromise? Facing cuts they basically brought upon themselves, dialysis providers and advocacy groups, including patient organizations dependent on industry funding, are saying that patient care will suffer, that dialysis centers may close, and that staff will be reduced. In fact, they are saying that life-saving therapy is at risk.
Build it, buy it…and build some more
If a business has thin profit margins, it doesn’t seem to make sense to expand. As the renal community is threatening to close clinics because of the bundled payment cut, they are also making announcements of new ones opening. DaVita has also made heavy investment in buying clinics overseas over the last two years and, of course, recently bought Healthcare Partners with $3.66 billion in cash and 9.38 million DaVita common shares.
In 2012-2013, the nation’s 10 largest dialysis providers, as ranked by NN&I each year, added 298 clinics, either via new construction or acquisition/consolidation. That was a big jump from 214 clinics added by this group in 2011-2012 and remains the largest growth in clinic ownership among the 10 largest providers over the last five years.
That expansion seems out of sorts with the declining growth in the patient population. At the end of 2010, U.S. Renal Data System data showed the number of new patients starting therapy on hemodialysis declined for the first time in more than three decades.
Specifically, according to the USRDS’ 2012 Annual Data Report: “…The total treated ESRD population [at the end of 2010] thus rose to 593,086 — growth of 4% from 2009, which is the smallest increase in 30 years. The rate of prevalent ESRD cases reached 1,752 per million population, an increase of 1.1% from 2009, and also the slowest growth in the last three decades.”
So why is an industry that complains about thin profit margins spending millions of dollars on building or acquiring clinics or other providers during a period when growth in new patients on dialysis is at its lowest in three decades? Again, is money going toward the bottom line, or patient care? Has the provider community been using profits to build or buy more bricks and mortar, and finding out the patients are coming?
EPO is the first to go
I believe what has brought on the bundle payment cut is similar to a confluence of circumstances — almost like a perfect storm, with dialysis patients the only ones in the water. The cutback on using injectable drugs was predictable. I remember speaking at the CMS Town Hall Meeting in October 2009 that underutilization of pharmaceuticals would be an unintended consequence of the bundle. More specifically I was concerned patients would suffer because of the fear if any money was taken out of the system that it would be taken out of patient care. And, our track record for dialysis patient care is less than stellar.
Compared to the rest of the industrialized world, we could be doing a lot better.
... Our mortality rate is the highest among developed countries.
... Home dialysis — the therapy I have chosen — is only being used by roughly 10% of patients in the United States, one of the lowest percentage penetration among developed countries. Ironically, 90% of nephrologists in the United States say in polls that they would pick home dialysis for themselves if they had to be on dialysis. It’s not clear to me why you would choose a superior modality for yourself but not recommend it to your patients.
... There is no serious attempt at rehabilitation of individuals once they go on dialysis. Unemployment between the prime working ages of 18-54 is 80%.2 A new study out this week shows that ESRD patients who are unemployed are less likely to be referred for a transplant. So the industry’s lack of interest in helping patients return to the workforce also clearly impacts their chances of getting a new kidney.
... For-profit dialysis providers, which make up the bulk of the industry, offer inferior care. In the article, “Patient care staffing levels and facility characteristics in U.S. hemodialysis facilities” published in June in the American Journal of Kidney Diseases, researchers noted that “ratios of RNs and LPNs to patients were 35% (P < 0.001) and 42% (P < 0.001) lower, respectively, but the PCT to patient ratio was 16% (P < 0.001) higher in for-profit than nonprofit facilities (rate ratios of 0.65 [95% CI, 0.63-0.68], 0.58 [95% CI, 0.51-0.65], and 1.16 [95% CI, 1.12-1.19], respectively).3
... We also learned from the Agency in Health Care Research and Quality in December 2011 that, “Compared with the nonprofit chain, mortality risk was 19% higher at one for-profit chain and 24% higher at a second for profit-chain. Overall, patients from for-profit facilities, regardless of chain status, had a 13% higher risk of mortality than non-profit facilities.”
Change in ESRD QIP also influential
Patients have been harmed by the underutilization of ESAs, and CMS can be partly blamed by helping providers push the ESA dosing envelope. The clinical measure to track hemoglobins in the ESRD QIP only penalizes clinics if patients go over 12 g/dL; there is no penalty for hemoglobins under 10 g/dL. That’s just a green light to providers to underutilize. And why an upper limit? It makes no sense and is counterintuitive. Providers are not going to spend the money to keep hemoglobin levels that high. But clearly there is an incentive to lower hemoglobins: reduce costs. One documented impact of lower ESA use and subsequent lower hemoglobins is the increase in transfusions, now estimated at approximately 20%.4
CMS has floated a new quality measure developed by Arbor Research that would bring the hemoglobin “floor” back, and its proposed 2014 QIP includes a clinical measure requiring clinics to report more about how they are using ESAs. That’s a step in the right direction. We need to make sure that ESA dose isn’t being dictated by bottom line calculations, but by what is best for the patient.
Is there a level playing field?
One thing needed is to level the playing field between the better performing small dialysis organizations and medium dialysis organizations and the lower performing large dialysis organizations. It is the small dialysis organizations and medium dialysis organizations that will likely be impacted most by the proposed cut. I would urge CMS to look at finding some way there can be a differential built into the PPS to ensure the smaller dialysis centers can survive and not be gobbled up by the LDOs. We cannot afford to lose them.
The bottom line (for dialysis patients and providers)
There has been a torrent of comments on social media regarding the proposed payment cut. I’ve never seen patients more engaged in an issue, as they are being told their lifeline therapy may be taken away. Patients are posting all over Facebook that they don’t want to die, including home dialyzors. I wish those home dialyzors would jump on a broader bandwagon and call on CMS to increase reimbursement for home hemodialysis training. Low home training reimbursement, particularly for home hemodialysis, is one barrier to growth in the United States.
The dialysis provider community is positioning the cuts as if they will affect future operations, including keeping centers open and maintaining staff levels. Nothing is said about increasing the utilization of medications to its appropriate levels, which was the cause of the proposed cuts in the first place. If the cuts are mitigated in any amount, the money should go back and reverse the care and service impacted in the past. Restore an appropriate level of ESAs and other biologicals. Reverse the trend of more dialysis patients requiring transfusions. Don’t play games with the fragility of dialysis patients’ lives. Let’s figure out the real impact of the cuts and sit down with CMS and negotiate a compromise. Scare tactics with patients at the center give the renal community a black eye.
References
1. Thamer M., Zhang Y, Dejian L, Kshirsagar O, Cotter D. Influence of safety warnings on ESA prescribing among dialysis patients using an interrupted time series.
BMC Nephrology 2013, 14:172 doi:10.1186/1471-2369-14-172
2. Table 20 ESRD Network Program 2011 Summary Annual Report
3. Yoder LA, Xin W, Norris KC, Yan G. Patient care staffing levels and facility characteristics in U.S. hemodialysis facilities, Am J Kidney Dis. 2013 Jun 27. pii: S0272-6386(13)00830-5. doi: 10.1053/j.ajkd.2013.05.007, USRDS 2011
4. Sack K. Unintended consequences for dialysis patients as drug rule changes, NY Times, May 11, 2012
Mr. Berkowitz is a home hemodialyzor from Skokie, Ill, and president and founder of Home Dialyzors United
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I'm sorry but in capitalism companies are formed to make money, either for individuals or stock holders. If these private companies go out of business and you have to count on the government hang on! We lived next to the Canadian boarder and people from Canada were paying out of pocket for .cancer treatments because they were on a one year waiting list in Canada! Socialism SUCKS!! Our system has problems but the free market is the only thing that dialysis patients have going for them. If these private clinic don't fight for you who will? It took me 5 years to find this site. (by accident). Our government is trying to demonizes big business but that is what made this country!! Support the effort of your clinics to save your rights to good care! They are spending their money to do it. My wife is a dialysis patient and as it is we have had to loose everything to get the help we get!! So I surely can't fight big brother but my wives clinic can.
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I'm sorry but in capitalism companies are formed to make money, either for individuals or stock holders. If these private companies go out of business and you have to count on the government hang on! We lived next to the Canadian boarder and people from Canada were paying out of pocket for .cancer treatments because they were on a one year waiting list in Canada! Socialism SUCKS!! Our system has problems but the free market is the only thing that dialysis patients have going for them. If these private clinic don't fight for you who will? It took me 5 years to find this site. (by accident). Our government is trying to demonizes big business but that is what made this country!! Support the effort of your clinics to save your rights to good care! They are spending their money to do it. My wife is a dialysis patient and as it is we have had to loose everything to get the help we get!! So I surely can't fight big brother but my wives clinic can.
That is the problem, health care should not be government or for profit, but instead, as it started as non-profit entities. I just transferred from Kaiser to Group Health. At Kaiser, FMC had a joint venture with Kaiser in several dialysis units. My experience in that Kaiser/FMC joint venture was all positive.
Now that I am with Group Health, the FMC unit here has no such arrangement and I am quite unhappy with this new unit. Today, they discussed reducing my dialysate for cost purposes even though they acknowledge that I am doing very well on my current treatment. When money matters more than people, that system will inevitably fail to provide for their patients. I have nothing against capitalism but it does NOT belong in the health care arena. My experience providing care in a non-profit for my patients was such that I was able to provide for their needs. The for-profit health care outfits cannot provide the level of care as a non-profit. So, agreed on the failure of socialism, but for-profit dialysis companies not the solution my friend.
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I'm sorry but in capitalism companies are formed to make money, either for individuals or stock holders. If these private companies go out of business and you have to count on the government hang on! We lived next to the Canadian boarder and people from Canada were paying out of pocket for .cancer treatments because they were on a one year waiting list in Canada! Socialism SUCKS!! Our system has problems but the free market is the only thing that dialysis patients have going for them. If these private clinic don't fight for you who will? It took me 5 years to find this site. (by accident). Our government is trying to demonizes big business but that is what made this country!! Support the effort of your clinics to save your rights to good care! They are spending their money to do it. My wife is a dialysis patient and as it is we have had to loose everything to get the help we get!! So I surely can't fight big brother but my wives clinic can.
I am a Milton Friedman trained economist and I was with Davita for five years. If you think Davita is existing to help me and your wife, you have been drinking. Thiry is out to help his own pocketbook, not your life..... I am NOT an Obama supporter, not ever, ever. Why would you build so many more dialysis clinics if you were not going to make money and why would Warren Buffet invest in your dialysis company, if he did not think you will be making money, Buffet is worth billions from stock picking. Good care, you have to be joking!!!!!
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Free Market or Capitalism is one thing.
Making huge profits off sick people and Medicare (aka taxpayers) is another.
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Free Market or Capitalism is one thing.
Making huge profits off sick people and Medicare (aka taxpayers) is another.
How much profit is too much?
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Free Market or Capitalism is one thing.
Making huge profits off sick people and Medicare (aka taxpayers) is another.
How much profit is too much?
When it comes to healthcare, all of it is too much. The differences between FMC in joint partnership with Kaiser and the level of support and supplies compared to FMC for-profit alone is the difference between night and day. The FMC/Kaiser experiment shows that a "for-profit" entity can be tamed by joining contractually with a non-profit by setting up a system to improve care and reduce secondary costs from ER visits and hospitalizations.
When I spoke to Ben Lipps a year and half ago in person, this was his vision of improved care in America. Then nephrologists are rewarded financially for keeping hospitalizations down. In such a system, the for profit entities can be tamed to provide cost effective care that is also the best for the patient.
In reality, the current system is not actually the "fault" of the for-profit entities alone. It all comes back to the wall between part A and part B of Medicare that produces a system where the outpatient facilities maximize their profits by denying care since they have NO responsibility for the in-patient costs from failing to provide the best care. So, when FMC joined with Kaiser in a capitated payment system with incentive bonuses for reducing hospitalizations, everyone benefits including the for-profit industry.
Long story short, for-profit medicine can actually provide excellent care if you simply change the incentives. CMS thus is at the heart of the horrible outcomes because of the wall between Part A and Part B. The FMC/Kaiser experiment demonstrated this in a profound manner. I miss that system greatly. Who is to blame then? FMC or CMS and congress for putting this disincentive to good care into the system controlled by the single payer Medicare ESRD program?
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But, what if you need to go to the hospital but they won't send you because they want the incentive? Any good idea is corrupted by someone.
I personally think Medicare has it right. DaVita charges what they want (65K per month) and medicare doesn't even look at what they want they GET $3,000. Like the Mom whose kid wants the whole box of cookies but she gives them 1.
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But, what if you need to go to the hospital but they won't send you because they want the incentive? Any good idea is corrupted by someone.
I personally think Medicare has it right. DaVita charges what they want (65K per month) and medicare doesn't even look at what they want they GET $3,000. Like the Mom whose kid wants the whole box of cookies but she gives them 1.
pm sent to Rerun
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In that article it says less people are starting dialysis. Why? I am 44 and I am part of the baby bust. We came after the baby boomers. My brother's graduating class was the lowest in number graduating for our area. Schools closed all over. After him, the classes increased every year. Are they buying and building dialysis centers for when the increasing population over 50 starts?
For places making lots of profit, the decreased bundle will only affect care if those centers allow it by cutting staff and medicines, etc. For many small rural clinics there will be a big effect. Those are the patients that can't change centers because there is no place else. Those studies that decide the centers don't need the money, are they based on a sampling or an average or what?
I'm sure docs would want to do home hemo but they have a certain confidence in their ability to handle it than many of us. I'm so shaky from Prograf that I can barely tie my own shoes. I don't think I could cannulate myself. I live alone so here they wouldn't let me do it anyway. If you live in a nursing home, you probably can't do home care because there's no room in your 600 sq ft apt.
The problem is that statistics need context. It's really hard for me to know which way my support goes. I know that when I went to dialysis, the only center in the county had 2 buildings about 5 miles apart owned by the same doctor group. There were no other options without a much longer drive. And this was only about 1 1/2 hours from Philadelphia. It's complicated.
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Dear Jeannea,
Self cannulation is a totally different endeavor than sticking a needle into someone else's arm or neck or stomach or back or chest or shoulder or knee or arm or leg. (Had to think of all the procedures I did as a doc) However, when it came to sticking my OWN arm, not easy at all despite the number of needles I had stuck in my patients over the many years. But it is the single most important determinant of survival in many years since most home patients self cannulate. Once you are able to get over the initial repulsion to sticking yourself, it becomes much easier with time. It becomes just something you have to do but the consolation is that most that stick themselves do it better than the nurses or techs and have less complications in the long run than even the "expert" cannulators.
Lastly, I did dialyze in a 500 sq. ft cottage we rented from Sept. 2009 to Sept. 2010. No, not much space, but we did manage to get things done and that was with 2000 pounds of dialysate bags each month. The PureFlow supply list is significantly less than the bags and in such, having a very small apartment is not an absolute reason to not consider home dialysis.
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Can that really be true that in NZ south island all hemo patients are at home? How does that work? If you can't handle doing it yourself do they send a nurse out? Or do they deny you care? It sounds impossible to me although an interesting dream.
I haven't been here for a long while. Hi Everyone. Sorry to resurrect this post but it worries me that you guys are nervous to do dialysis on your own. I was googling something else and your quote came up jeannea. I am in Australia and I have been on dialysis now for six years. I do it at home on my own. It really is not a big deal and I have been doing the same thing for six years. I work full time, do dialysis every second day/night and that has been my smooth routine for years. Techs come out once every few months to check the machine and I never call on the nurses. The only problem I have had is a blocked access a couple of times which has nothing to do with home dialysis. That gets reviewed and I am home the same day.
I am sorry you guys over there are nervous about doing it at home yourselves - and that you are not allowed to do it at home by yourselves. The bottom line is it is almost impossible to kill yourself. It has just become a way of life and an extension of my day. I don't want a transplant - I am happy with being on my machine. It is barely a blimp for me. I hope everyone is doing well and lots of love to everyone. http://ihatedialysis.com/forum/Smileys/classic/new_flower.gif
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You have a great attitude. Keep up the good work.
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Personally I don't know if I could do it. I have a very bad hand tremor from Prograf that didn't even go away when I was on dialysis between transplants and not taking Prograf. But when I made that comment I was thinking more about older people who cannot handle the set up or bedridden people who can't do things like that or even someone too scared. It seemed impossible to me to have everyone on home treatment unless you send the scared person home to die. Here in the US I would not be permitted to do home hemo. I live all alone, not married or anyone else. Centers here will not train you alone.