Video from RSN presenting the concerns about expanding the dialysis bundle

[Bill Peckham]

http://www.billpeckham.com/from_the_sharp_end_of_the/2008/05/video-from-rsn.html

This video from the Renal Support Network is good and not just because I appear three times (is it just me or does my lighting seem off?). I've written plenty on expanding the dialysis bundle aka the ESRD composite rate - thousands of words - I think this video covers the ground better in six and a half minutes than I did in all those posts.

[Sluff]

Good video indeed, I think it was your red wine colored shirt Bill.

[Rerun]

How much money do we need to spend on education???  For God's Sake we have tons of information on the internet.  If you don't have the disease you don't want to hear about it. 
If you have the disease you can get online and learn ALL about it from diet to access options.  We need to spend MONEY on education for organ donation.  This bundling talks a lot about education.  Does that mean we hire more idiot Social Workers to come around and shove information in our face while we are on the machine?  Screw that!

If they cut any of our services we need to kick some CEO in the ass and have him cut his salary. 

[Zach]

When an organization (RSN) receives hundreds of thousands of dollars from the "Caring Kidney" industry, what else should you expect?

 

[Rerun]

When an organization receives hundreds of thousands of dollars from the "Caring Kidney" industry, what else should you expect?

 

How about a kick-back to the patients for choosing their facility!   

[Bill Peckham]

How much money do we need to spend on education???  For God's Sake we have tons of information on the internet.  If you don't have the disease you don't want to hear about it. 
If you have the disease you can get online and learn ALL about it from diet to access options.  We need to spend MONEY on education for organ donation.  This bundling talks a lot about education.  Does that mean we hire more idiot Social Workers to come around and shove information in our face while we are on the machine?  Screw that!

If they cut any of our services we need to kick some CEO in the ass and have him cut his salary. 

The new education elements of the proposed bills - HR6331 (previously S3101 & S3118 were the vehicles, but the House bill HR6331 has trumped them ... from a CKD perspective all three bills are equivalent) is for CKD 3 and 4 education. You're safe Rerun.

When an organization (RSN) receives hundreds of thousands of dollars from the "Caring Kidney" industry, what else should you expect?

 

DaVita and FMC are in favor of expanding the bundle - it will encourage further industry consolidation. This video brings up that concern as well as other concerns about expanding the bundle. I don't think this was an apt time to trot out the "everyone is bought and paid for" canard.

Surely you have some other angle on how RSN comes to a position. Or is only money, always?

[Zach]

Yes Bill, unfortunately you sometimes need to follow the money.

Look at the wording of their new alert about the annual "update."  Message from Kidney Care Partners 6-30-08:  " ... provide an inflationary update to account for critical staffing services."  Sounds really nice.  This is the new language that the "Caring Kidney" folks are pushing.

But unless we have a standard for staffing/patient ratios, such as one Patient Care Technician for every four patients, or one RN for every 10 patients, this update is not guaranteed to go towards proper staffing.  Didn't we have enough of the "trickle-down" theories?

And how is this inflationary update measured?  Is it as simple as the Consumer Price Index?  Or does it measure price variations in the medical field--some of which are controlled by the very same members of the "Caring Kidney" lobby (pharma & suppliers).

RSN provides the minimum of information and allows the dialysis industry to control the agenda.  RSN needs to give us some idea how much more this "inflationary update" will add over a certain period of time.  Something such as the way the GAO analyzes the potential cost of proposed bills.

Perhaps a study of this "inflationary update" based on the costs from 1995 to 2005.  How much more would hemodialysis reimbursement be at the end of that period of time compared to what it actually was?

[Bill Peckham]

http://www.billpeckham.com/from_the_sharp_end_of_the/2008/06/congressional-b.html
Congressional Budget Office reckoning of the financial impact of HR6331

RSN has tried to discuss the issue with people who have kidney disease in a number of ways. There is a monthly conference call, there is a listserv ...
They published a paper after having a two day meeting http://www.rsnhope.org/1weKAN/BundlingPatientPerspective08.pdf
They've tried top ten lists http://www.rsnhope.org/WeKANAdvocacy/BundlingStatementFinal-5-31-07.pdf
They tried via podcast Are We Ready to Bundle? -  KidneyTalk Show http://www.rsnhope.org/programs/kidneytalkshows/Mike_Lazarus/index.php

RSN's weKAN advocacy effort is a very bottom up structure. The advocacy is the product of group effort to address the questions and concerns of the group. If you have questions or concerns you could work through them to have them addressed. They will assimilate your concerns. They're like the Borg, only happier.

As far as the amount of the inflation update -  the legislation leaves it up to the Secretary of DHHS. This would put dialysis in line with every other Medicare program - nursing home, rehab, other outpatient services, hospitals, docs, etc.

This is it. This is the Medicare legislation. There is no plan B that couples staffing ratios with the update. Ifthis does not pass then it will be another cycle of 3? 5? 7? years of nothing happening and the continued devaluation of the value of dialysis reimbursement.

This bill starts by cutting the entire program by 2% and between now and 2011 there is one permanent 1% update and one temporary update (in 2010 reimbursement is adjusted but the adjustment is not added to the base). I think if you looked into the legislation you'd find a lot you'll like - there is a withhold ... it takes money out of the dialysis program from units that have poor performance measures.

[Zach]

Not quite an answer.  And didn't expect much.

[Bill Peckham]

Didn't we have enough of the "trickle-down" theories?

Yes. Yes we did.

And how is this inflationary update measured?

The update is determined by the Secretary of DHHS in the same way that updates for other Medicare programs are determined - by measuring the costs of inputs - largely wage inflation.

Is it as simple as the Consumer Price Index?

No it measures the costs of inputs - largely wage inflation of staff. Wage costs are currently about 50% of the composite rate components - this percentage would go down in an expanded bundle - which is why the large chains are in favor of expanding the bundle. The LDOs can't get staff much cheaper than the small dialyis organizations but they sure can get medications and labs for less.

Or does it measure price variations in the medical field--some of which are controlled by the very same members of the "Caring Kidney" lobby (pharma & suppliers).

I know you are familiar with the MedPAC analysis of dialysis costs so you know that their recommendations are largely based on labor inputs minus an imagined productivity gain. This is typically what is done in other parts of Medicare but this legislation limits updates to market basket less 1% forever (the 1% decrease doesn't end after 10 years).

RSN needs to give us some idea how much more this "inflationary update" will add over a certain period of time.  Something such as the way the GAO analyzes the potential cost of proposed bills.

WHat's your beef with the Congressional Budget Office analysis? The GAO doesn't score legislation that I know of.

Perhaps a study of this "inflationary update" based on the costs from 1995 to 2005.  How much more would hemodialysis reimbursement be at the end of that period of time compared to what it actually was?

There's inflation calculators available on the internets but I'm not sure why you'd put stock in the number. Is there some question about the impact of inflation in dialysis? Is there some doubt that with inflation adjustments reimbursement would be more than it now is? You assume that any increase would have been siphoned off as profits and we'd have the exact same care as today - I dispute that. I find that counter intuitive. I believe that if reimbursement had been adjusted, if more money had been paid per treatment, then care would have been better over the ten year period.

[Zach]

Thank you, Bill, for your responses to my questions.
 

[dialysisbiller]

very insightful Bill.

It seems as if you support an increase for dialysis reimbursement. (I'm tired and maybe I read the whole post wrong)

I think people see the money CEOs rake in and it totally pisses them off because they're local center is crap. Personally, bigger isn't always better and I hope they realise that. FMS is bigger yet but people don't see the numbers of it's higher ups. I've tried looking them up. Any insight to what FMS is earning on dialysis? I think I read one article that they had a profit increase in 2008 like Davita.