S 691 and H.R. 1193 the `Kidney Care Quality and Education Act of 2007'

[Bill Peckham]

110th CONGRESS

1st Session

H. R. 1193

To amend title XVIII of the Social Security Act to improve the benefits under the Medicare Program for beneficiaries with kidney disease, and for other purposes.

IN THE HOUSE OF REPRESENTATIVES

February 27, 2007

Mr. LEWIS of Georgia (for himself, Mr. CAMP of Michigan, Mr. BISHOP of Georgia, Mr. WYNN, Ms. KILPATRICK, Mr. BUTTERFIELD, and Mr. CUMMINGS) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

A BILL

To amend title XVIII of the Social Security Act to improve the benefits under the Medicare Program for beneficiaries with kidney disease, and for other purposes.

      Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

      (a) Short Title- This Act may be cited as the `Kidney Care Quality and Education Act of 2007'.

      (b) Table of Contents- The table of contents for this Act is as follows:

            Sec. 1. Short title; table of contents.

TITLE I--IMPROVING QUALITY THROUGH PATIENT EDUCATION, ACCESS, AND SAFETY INITIATIVES

            Sec. 101. Support of public and patient education initiatives regarding kidney disease.

            Sec. 102. Medicare coverage of kidney disease patient education services.

            Sec. 103. Blood flow monitoring demonstration projects.

            Sec. 104. Institute of Medicine evaluation and report on treatment modalities for patients with kidney failure.

            Sec. 105. Required training for patient care dialysis technicians.

TITLE II--ASSURING QUALITY OF CARE FOR PROVIDERS, FACILITIES, AND PHYSICIANS THAT PROVIDE SERVICES TO INDIVIDUALS WITH END-STAGE RENAL DISEASE WHO ARE ENROLLED IN PART B

            Sec. 201. Establishment of the End-Stage Renal Disease (ESRD) Advisory Committee.

            Sec. 202. Update for the Medicare ESRD composite rate for 2008, 2009, and 2010.

            Sec. 203. Continuous quality improvement initiative in the Medicare end-stage renal disease program.

            Sec. 204. Extension of Medicare secondary payer.

TITLE I--IMPROVING QUALITY THROUGH PATIENT EDUCATION, ACCESS, AND SAFETY INITIATIVES

SEC. 101. SUPPORT OF PUBLIC AND PATIENT EDUCATION INITIATIVES REGARDING KIDNEY DISEASE.

      (a) Chronic Kidney Disease Demonstration Projects-

            (1) IN GENERAL- The Secretary of Health and Human Services (in this section referred to as the `Secretary') shall establish demonstration projects to--

                  (A) increase public awareness about the factors that lead to chronic kidney disease, how to prevent it, how to treat it, and how to avoid kidney failure; and

                  (B) enhance surveillance systems and expand research to better assess the prevalence and incidence of chronic kidney disease.

            (2) SCOPE AND DURATION-

                  (A) SCOPE- The Secretary shall select at least 3 States in which to conduct demonstration projects under this subsection. In selecting the States under this subparagraph, the Secretary shall take into account the size of the population of individuals with end-stage renal disease who are enrolled in part B of title XVIII of the Social Security Act and ensure the participation of individuals who reside in rural and urban areas.

                  (B) DURATION- The demonstration projects under this subsection shall be conducted for a period that is not longer than 5 years that begins on January 1, 2009.

            (3) EVALUATION AND REPORT-

                  (A) EVALUATION- The Secretary shall conduct an evaluation of the demonstration projects conducted under this subsection.

                  (B) REPORT- Not later than 6 months after the date on which the demonstration projects under this subsection are completed, the Secretary shall submit to Congress a report on the evaluation conducted under subparagraph (A) together with recommendations for such legislation and administrative action as the Secretary determines appropriate.

            (4) AUTHORIZATION OF APPROPRIATIONS- There are authorized to be appropriated to carry out this subsection $2,000,000 for each of fiscal years 2009 through 2013.

      (b) ESRD Self-Management Demonstration Projects-

            (1) IN GENERAL- The Secretary shall establish demonstration projects to enable individuals with end-stage renal disease to develop self-management skills.

            (2) APPLICATION- The provisions of paragraph (2) (relating to scope and duration) and paragraph (3) (relating to an evaluation and a report) of subsection (a) shall apply to the demonstration projects under this subsection in the same manner as such provisions apply to the demonstration projects under subsection (a).

            (3) AUTHORIZATION OF APPROPRIATIONS- There are authorized to be appropriated to carry out this subsection $2,000,000 for each of fiscal years 2009 through 2013.

SEC. 102. MEDICARE COVERAGE OF KIDNEY DISEASE PATIENT EDUCATION SERVICES.

      (a) Coverage of Kidney Disease Education Services-

            (1) COVERAGE- Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended--

                  (A) in subparagraph (Z), by striking `and' after the semicolon at the end;

                  (B) in subparagraph (AA), by adding `and' after the semicolon at the end; and

                  (C) by adding at the end the following new subparagraph:

                  `(BB) kidney disease education services (as defined in subsection (ccc));'.

            (2) SERVICES DESCRIBED- Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection:

`Kidney Disease Education Services

      `(ccc)(1) The term `kidney disease education services' means educational services that are--

            `(A) furnished to an individual with kidney disease who, according to accepted clinical guidelines identified by the Secretary, will require dialysis or a kidney transplant;

            `(B) furnished, upon the referral of the physician managing the individual's kidney condition, by a qualified person (as defined in paragraph (2)); and

            `(C) designed--

                  `(i) to provide comprehensive information regarding--

                        `(I) the management of comorbidities;

                        `(II) the prevention of uremic complications; and

                        `(III) each option for renal replacement therapy (including home and in-center as well as vascular access options and transplantation); and

                  `(ii) to ensure that the individual has the opportunity to actively participate in the choice of therapy.

      `(2) The term `qualified person' means--

            `(A) a physician (as described in subsection (r)(1));

            `(B) an individual who--

                  `(i) is--

                        `(I) a registered nurse;

                        `(II) a registered dietitian or nutrition professional (as defined in subsection (vv)(2));

                        `(III) a clinical social worker (as defined in subsection (hh)(1));

                        `(IV) a physician assistant, nurse practitioner, or clinical nurse specialist (as those terms are defined in subsection (aa)(5)); or

                        `(V) a transplant coordinator; and

                  `(ii) meets such requirements related to experience and other qualifications that the Secretary finds necessary and appropriate for furnishing the services described in paragraph (1); or

            `(C) a renal dialysis facility subject to the requirements of section 1881(b)(1) with personnel who--

                  `(i) provide the services described in paragraph (1); and

                  `(ii) meet the requirements of subparagraph (A) or (B).

      `(3) The Secretary shall develop the information to be provided under paragraph (1)(C)(i) and the requirements under (2)(B)(ii) after consulting with physicians, health educators, professional organizations, accrediting organizations, kidney patient organizations, dialysis facilities, transplant centers, network organizations described in section 1881(c)(2), and other knowledgeable persons.

      `(4) In promulgating regulations to carry out this subsection, the Secretary shall ensure that each beneficiary who is entitled to kidney disease education services under this title receives such services in a timely manner to maximize the benefit of those services.

      `(5) The Secretary shall monitor the implementation of this subsection to ensure that beneficiaries who are eligible for kidney disease education services receive such services in the manner described in paragraph (4).

      `(6) No individual shall be eligible to be provided more than 6 sessions of kidney disease education services under this title.'.

            (3) PAYMENT UNDER THE PHYSICIAN FEE SCHEDULE- Section 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w-4(j)(3)) is amended by inserting `(2)(BB),' after `(2)(AA),'.

            (4) PAYMENT TO RENAL DIALYSIS FACILITIES- Section 1881(b) of the Social Security Act (42 U.S.C. 1395rr(b)) is amended by adding at the end the following new paragraph:

            `(14) For purposes of paragraph (12), the single composite weighted formulas determined under such paragraph shall not take into account the amount of payment for kidney disease education services (as defined in section 1861(ccc)). Instead, payment for such services shall be made to the renal dialysis facility on an assignment-related basis under section 1848.'.

            (5) LIMITATION ON NUMBER OF SESSIONS- Section 1862(a)(1) of the Social Security Act (42 U.S.C. 1395y(a)(1)) is amended--

                  (A) in subparagraph (M), by striking `and' at the end;

                  (B) in subparagraph (N), by striking the semicolon at the end and inserting `, and'; and

                  (C) by adding at the end the following new subparagraph:

                  `(O) in the case of kidney disease education services (as defined in section 1861(ccc)), which are performed in excess of the number of sessions covered under such section;'.

            (6) ANNUAL REPORT TO CONGRESS- Not later than April 1, 2009, and annually thereafter, the Secretary of Health and Human Services shall submit a report to Congress on the number of Medicare beneficiaries who are entitled to kidney disease education services (as defined in section 1861(ccc) of the Social Security Act, as added by paragraph (2)) under title XVIII of such Act and who receive such services, together with such recommendations for legislative and administrative action as the Secretary determines to be appropriate to fulfill the legislative intent that resulted in the enactment of that subsection.

      (b) Effective Date- The amendments made by this section shall apply to services furnished on or after January 1, 2009.

SEC. 103. BLOOD FLOW MONITORING DEMONSTRATION PROJECTS.

      (a) Establishment- The Secretary of Health and Human Services (in this section referred to as the `Secretary') shall establish demonstration projects to evaluate how blood flow monitoring affects the quality and cost of care for Medicare beneficiaries with end-stage renal disease.

      (b) Duration- The demonstration projects under this section shall be conducted for a period of not longer than 5 years that begins on January 1, 2009.

      (c) Evaluation and Report-

            (1) EVALUATION- The Secretary shall conduct an evaluation of the demonstration projects conducted under this section.

            (2) REPORT- Not later than 6 months after the date on which the demonstration projects under this section are completed, the Secretary shall submit to Congress a report on the evaluation conducted under paragraph (1) together with recommendations for such legislation and administrative action as the Secretary determines appropriate.

      (d) Waiver Authority- The Secretary shall waive compliance with the requirements of title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) to the extent, and for such period as, the Secretary determines is necessary to conduct the demonstration projects.

      (e) Authorization of Appropriations-

            (1) IN GENERAL- Payments for the costs of carrying out the demonstration projects under this section shall be made from the Federal Supplementary Medical Insurance Trust Fund under section 1841 of the Social Security Act (42 U.S.C. 1395t).

            (2) AMOUNT- There are authorized to be appropriated from such Trust Fund $1,000,000 for each of fiscal years 2009 through 2013 to carry out this section.

SEC. 104. INSTITUTE OF MEDICINE EVALUATION AND REPORT ON TREATMENT MODALITIES FOR PATIENTS WITH KIDNEY FAILURE.

      (a) Evaluation-

            (1) IN GENERAL- Not later than 2 months after the date of enactment of this Act, the Secretary of Health and Human Services (in this section referred to as the `Secretary') shall enter into an arrangement under which the Institute of Medicine of the National Academy of Sciences (in this section referred to as the `Institute') shall conduct an evaluation of the barriers that exist to increasing the number of individuals with end-stage renal disease who elect to receive home dialysis services or other treatment modalities under the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.).

            (2) SPECIFIC MATTERS EVALUATED- In conducting the evaluation under paragraph (1), the Institute shall--

                  (A) compare current Medicare home dialysis costs and payments with current in-center and hospital dialysis costs and payments;

                  (B) catalogue and evaluate the incentives and disincentives in the current reimbursement system that influence whether patients receive home dialysis services or other treatment modalities;

                  (C) evaluate patient education services and how such services impact the treatment choices made by patients; and

                  (D) consider such other matters as the Institute determines appropriate.

            (3) SCOPE OF REVIEW- In conducting the evaluation under paragraph (1), the Institute shall consider a variety of perspectives, including the perspectives of physicians, other health care professionals, hospitals, dialysis facilities, health plans, purchasers, and patients.

      (b) Report- Not later than 19 months after the date of enactment of this Act, the Institute shall submit to the Secretary and to Congress a report on the evaluation conducted under subsection (a)(1). Such report shall contain a detailed description of the findings of such evaluation and recommendations for implementing incentives to encourage patients to elect to receive home dialysis services or other treatment modalities under the Medicare program.

      (c) Authorization of Appropriations- There are authorized to be appropriated such sums as may be necessary for the purposes of conducting the evaluation and preparing the report required by this section.

SEC. 105. REQUIRED TRAINING FOR PATIENT CARE DIALYSIS TECHNICIANS.

      (a) In General- Section 1881 of the Social Security Act (42 U.S.C. 1395rr) is amended by adding the following new subsection:

      `(h)(1) Except as provided in paragraph (3), beginning January 1, 2009, a provider of services or a renal dialysis facility may not use any individual as a patient care dialysis technician for more than 4 months unless the individual--

            `(A) has completed a training program in the care and treatment of an individual with chronic kidney failure who is undergoing dialysis treatment;

            `(B) has been certified by a nationally recognized certification entity for dialysis technicians; and

            `(C) is competent to provide dialysis-related services.

      `(2) Beginning January 1, 2010, a provider of services or a renal dialysis facility may not use on a temporary, per diem, leased, or on any basis other than as a permanent employee, any individual as a patient care dialysis technician unless the individual meets the requirements described in subparagraphs (A), (B), and (C) of paragraph (1).

      `(3) A provider of services or a renal dialysis facility may permit an individual enrolled in a training program described in paragraph (1)(A) to serve as a patient care dialysis technician while they are so enrolled.

      `(4) For purposes of paragraph (1), if, since the most recent completion by an individual of a training program described in paragraph (1)(A), there has been a period of 24 consecutive months during which the individual has not performed dialysis-related services for monetary compensation, such individual shall be required to complete a new training program or become recertified as described in paragraph (1)(B).

      `(5) A provider of services or a renal dialysis facility shall provide such regular performance review and regular in-service education as assures that individuals serving as patient care dialysis technicians for the provider or facility are competent to perform dialysis-related services.'.

TITLE II--ASSURING QUALITY OF CARE FOR PROVIDERS, FACILITIES, AND PHYSICIANS THAT PROVIDE SERVICES TO INDIVIDUALS WITH END-STAGE RENAL DISEASE WHO ARE ENROLLED IN PART B

SEC. 201. ESTABLISHMENT OF THE END-STAGE RENAL DISEASE (ESRD) ADVISORY COMMITTEE.

      (a) In General- Pursuant to section 222 of the Public Health Service Act (42 U.S.C. 217a), the Secretary of Health and Human Services (in this section referred to as the `Secretary') shall establish within 1 year of the date of enactment of this Act an independent, multidisciplinary, nonpartisan End-Stage Renal Disease Advisory Committee (in this section referred to as the `Committee').

      (b) Membership-

            (1) IN GENERAL- The Committee shall consist of such members as the Secretary may appoint who shall serve for such term as the Secretary may specify. The Secretary shall ensure that a representative of the Centers for Medicare & Medicaid Services is included among the members of the Committee.

            (2) CONSULTATION- In appointing members of the Committee, the Secretary shall consult with patients, facilities and providers, physicians, nurses, a representative from the pediatric community, payers and insurers, manufacturers, and a representative of the Centers for Medicare & Medicaid Services who coordinates activities related to end-stage renal disease within the Centers.

      (c) Purpose of the Committee-

            (1) DUTIES- The Committee shall provide a forum for expert discussion and deliberation and the formulation of advice and recommendations to the Secretary regarding Medicare coverage for individuals with end-stage renal disease, as described under section 1881 of the Social Security Act (42 U.S.C. 1395rr).

            (2) RECOMMENDATIONS-

                  (A) ANNUAL RECOMMENDATIONS- The Committee shall provide annual recommendations to the Secretary regarding--

                        (i) selecting, modifying, and updating clinical and quality of life measures;

                        (ii) modifying the payment structure;

                        (iii) determining hardship criteria to exempt certain facilities and providers from the program; and

                        (iv) other issues related to implementation of a quality initiative by the Secretary.

                  (B) PERIODIC RECOMMENDATIONS- The Committee shall provide periodic advice and recommendations to the Secretary regarding Medicare coverage for individuals with end-stage renal disease, as described in such section 1881.

SEC. 202. UPDATE FOR THE MEDICARE ESRD COMPOSITE RATE FOR 2008, 2009, AND 2010.

      Section 1881(b)(12)(G) of the Social Security Act (42 U.S.C. 1395rr(b)(12)(G)), as amended by section 103 of the Tax Relief and Health Care Act of 2006 (Public Law 109-432), is amended--

            (1) in clause (i), by striking `and' at the end;

            (2) in clause (ii)--

                  (A) by inserting `and before January 1, 2008,' after `April 1, 2007'; and

                  (B) by striking the period at the end and inserting a semicolon; and

            (3) by adding at the end the following new clauses:

            `(iii) furnished during 2008, by the amount equal to the ESRD market basket (as developed pursuant to section 422(b) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (Public Law 106-554), as enacted into law by section 1(a)(6) of Public Law 106-554) percentage increase for 2008 above the amount of such composite rate component for such services furnished on December 31, 2007;

            `(iv) furnished during 2009, by the amount equal to the ESRD market basket (as so developed) percentage increase for 2009 above the amount of such composite rate component for such services furnished on December 31, 2008; and

            `(v) furnished on or after January 1, 2010, by the amount equal to the ESRD market basket (as so developed) percentage increase for 2010 above the amount of such composite rate component for such services furnished on December 31, 2009.'.

SEC. 203. CONTINUOUS QUALITY IMPROVEMENT INITIATIVE IN THE MEDICARE END-STAGE RENAL DISEASE PROGRAM.

      (a) Establishment of the Program- Section 1881 of the Social Security Act (42 U.S.C. 1395rr), as amended by section 105, is amended by adding at the end the following new subsection:

      `(i) Continuous Quality Improvement Initiative in the End-Stage Renal Disease Program-

            `(1) IN GENERAL- Not later than January 1, 2008, the Secretary shall establish a 3-year continuous quality improvement initiative (in this section referred to as the `quality initiative') under which quality payments are provided to renal dialysis facilities, providers of services, and physicians that provide items and services to individuals with end-stage renal disease who are enrolled under part B and that meet quality benchmarks and demonstrate quality improvements.

            `(2) PARTICIPATION-

                  `(A) FACILITIES AND PROVIDERS-

                        `(i) IN GENERAL- Except as provided in subparagraph (C)(i) and subject to clause (ii), all independent dialysis facilities and hospital-based dialysis providers that provide items and services to individuals with end-stage renal disease who are enrolled in part B shall participate in the quality initiative.

                        `(ii) POSITIVE UPDATE REQUIRED- The quality initiative shall not apply to facilities and providers in a year unless the ESRD market basket percentage increase described in subsection (b)(12)(G) for such year is positive.

                  `(B) PHYSICIANS-

                        `(i) IN GENERAL- Except as provided in subparagraph (C)(i) and subject to clause (ii), all physicians who receive the monthly capitated payment under this title with respect to end-stage renal disease items and services shall participate in the quality initiative.

                        `(ii) POSITIVE UPDATE REQUIRED- The quality initiative shall not apply to physicians in a year unless the update to the conversion factor under section 1848(d) for such year is positive.

                  `(C) PEDIATRIC FACILITIES, PROVIDERS, AND PHYSICIANS-

                        `(i) IN GENERAL- Subject to clause (ii), a pediatric facility, provider, or physician who provides items and services to individuals with end-stage renal disease who are enrolled in part B and with at least 50 percent of its patients being individuals under 18 years of age shall be required to report data for pediatric-specific measures under this subsection in order to receive the full market basket update during 2008, 2009, and 2010 under subsection (b)(12)(G) or the full update under section 1848(d).

                        `(ii) POSITIVE UPDATE REQUIRED- The reporting requirement under clause (i) shall not apply to--

                              `(I) pediatric facilities and providers in a year unless the ESRD market basket percentage increase described in subsection (b)(12)(G) for such year is positive; and

                              `(II) to pediatric physicians in a year unless the update to the conversion factor under section 1848(d) for such year is positive.

                        `(iii) EVALUATION- The Secretary, in consultation with the End-Stage Renal Disease Advisory Committee established under section 201 of the Kidney Care Quality and Education Act of 2007 (in this subsection referred to as the `ESRD Advisory Committee'), shall evaluate and make recommendations to Congress regarding the feasibility of incorporating pediatric facilities, providers, and physicians described in clause (i) fully into the quality initiative if the initiative were to extend beyond 2010.

            `(3) DURATION- The quality initiative shall be conducted during a period of 3 years beginning January 1, 2008.

            `(4) FUNDING-

                  `(A) BONUS POOL FOR PROVIDERS AND FACILITIES- During 2008, 2009, and 2010, the Secretary shall set aside at least 1/4 , but no more than 1/2 , of the ESRD market basket amount under subsection (b)(12)(G) for each year, respectively, to establish a bonus pool to be used to provide bonus payments for providers and facilities described in paragraph (2)(A) that demonstrate improvements in quality or attainment of quality benchmarks.

                  `(B) BONUS POOL FOR PHYSICIANS- During 2008, 2009, and 2010, the Secretary shall set aside at least 1/4 , but no more than 1/2 , of the portion of the physician fee schedule update under section 1848(d) that applies to physicians who receive the monthly capitated payment under this title with respect to end-stage renal disease items and services for each year respectively to establish a bonus pool to be used to provide bonus payments for physicians described in paragraph (2)(B) that demonstrate improvements in quality or attainment of quality benchmarks.

            `(5) ESTABLISHMENT OF QUALITY INCENTIVE PAYMENTS-

                  `(A) INCENTIVES FOR REPORTING IN 2008-

                        `(i) IN GENERAL- During 2008, the Secretary shall make quality incentive payments from the bonus pool described in paragraph (4)(A) to facilities and providers and from the bonus pool described in paragraph (4)(B) to physicians described in subparagraphs (A) and (B) of paragraph (2) for reporting data about clinical and quality of life measures adopted by the Secretary in consultation with the ESRD Advisory Committee.

                        `(ii) EXTENSION- If the Secretary determines that there are problems associated with reporting that should be resolved before implementing the quality payment system under subparagraph (B), the Secretary may extend the reporting period an additional year.

                        `(iii) EXCEPTION TO REPORTING REQUIREMENT- The Secretary shall establish criteria for an application for a hardship exception that would allow small or rural facilities and providers to receive the full update under subsection (b)(12)(G) even if they are not able to report data.

                  `(B) QUALITY INCENTIVE PAYMENTS IN 2009 AND 2010-

                        `(i) IN GENERAL- During 2009 and 2010, the Secretary shall make quality incentive payments from their respective bonus pools under paragraph (4) to facilities, providers, and physicians described in subparagraphs (A) and (B) of paragraph (2) with respect to a year if the Secretary determines that the quality of care provided in that year by the facility, provider, or physician to individuals with end-stage renal disease who are enrolled under part B--

                              `(I) has substantially improved (as determined by the Secretary in consultation with the ESRD Advisory Committee) over the prior year; or

                              `(II) exceeds a threshold established by the Secretary in consultation with the ESRD Advisory Committee.

                        `(ii) REQUIREMENTS- In determining which facilities, providers, or physicians qualify for the quality incentive payments under clause (i), the Secretary shall do the following:

                              `(I) Adopt clinical and quality of life measures in consultation with the ESRD Advisory Committee.

                              `(II) For 2008, ensure that payments will be based on the reporting of data regarding clinical and quality of life measures adopted by the Secretary in consultation with the ESRD Advisory Committee.

                              `(III) For 2009 and 2010, subject to subparagraph (C), ensure that payments will be based upon the composite score awarded to the facilities, providers, and physicians. The composite score will be based upon the submission of data about clinical and quality of life measures adopted by the Secretary in consultation with the ESRD Advisory Committee.

                  `(C) DETERMINATION OF AMOUNT OF INCENTIVE PAYMENT-

                        `(i) IN GENERAL- Subject to clause (ii), the Secretary shall determine the amount of a quality incentive payment to a facility, provider, or physician based upon a quintile scale of a weighted composite score of clinical and quality of life measures.

                        `(ii) LIMITATION- The Secretary shall establish the quality incentive payments so that the total amount of such payments made in a year--

                              `(I) to facilities and providers from the bonus pool under paragraph (4)(A) is equal to the total amount available for such payments for the year under such paragraph; and

                              `(II) to physicians from the bonus pool under paragraph (4)(B) is equal to the total amount available for such payments for the year under such paragraph.

                  `(D) REQUIREMENTS FOR ESTABLISHMENT OF THE COMPOSITE SCORE- In establishing the composite score under this subsection, the Secretary shall--

                        `(i) consult with the ESRD Advisory Committee to develop the clinical and quality of life measures and formula used to calculate the weighted composite score;

                        `(ii) use a transparent process consistent with the requirements of chapter 5 of title 5, United States Code (commonly referred to as the `Administrative Procedure Act') to develop the measures and the formula used to calculate the weighted composite score; and

                        `(iii) assure that the payments reward facilities, providers, and physicians for--

                              `(I) the attainment of minimum quality targets; and

                              `(II) substantial improvement over the previous year, as demonstrated by the movement of a facility, provider, or physician from 1 quintile to another.

            `(6) REQUIREMENTS FOR INCENTIVE PAYMENTS-

                  `(A) IN GENERAL- In order for a facility, provider, or physician to be eligible for quality incentive payments described in paragraph (5) for a year, the provider, facility, or physician must have provided for the submission of data in accordance with subparagraph (B) with respect to that year.

                  `(B) SUBMISSION OF DATA- For 2008, 2009, and 2010, each facility, provider, and physician described in subparagraphs (A) and (B) of paragraph (2) shall submit to the Secretary such data that the Secretary determines are appropriate for the measurement of health outcomes and other indices of quality, including data necessary for the operation of the continuous quality improvement initiative under this subsection. Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this subsection.

                  `(C) ATTESTATION REGARDING DATA- In order for a facility, provider, or physician to be eligible for a quality incentive payment under this subsection for a year, the facility, provider, or physician must have provided the Secretary (under procedures established by the Secretary in consultation with the ESRD Advisory Committee) with an attestation that the data submitted under this subsection for the year are complete and accurate.

            `(7) PAYMENT METHODS AND TIMING OF PAYMENT-

                  `(A) IN GENERAL- Subject to subparagraph (B), the payment of quality incentive payments shall be based on such method as the Secretary, in consultation with the ESRD Advisory Committee, determines appropriate.

                  `(B) TIMING- The Secretary shall ensure that quality incentive payments with respect to a year are made by no later than June 30 of the subsequent year.

            `(8) FEEDBACK- The Secretary shall provide quality incentive payments and feedback to facilities, providers, and physicians as frequently as possible and as close to the date on which such facilities, providers, and physicians submitted quality data.

            `(9) TECHNICAL ASSISTANCE- The Secretary shall identify or establish an appropriately skilled group or organization, such as the ESRD Networks, to provide technical assistance to consistently low-performing facilities, providers, or physicians that are in the bottom quintile.

            `(10) STREAMLINE REPORTING- The Secretary shall--

                  `(A) evaluate the current data systems used by facilities, providers, and physicians to submit data; and

                  `(B) eliminate redundant reporting by consolidating all current data reporting into a new web-based system in order to minimize redundancy and reduce regulatory and administrative demands.

            `(11) PUBLIC REPORTING-

                  `(A) AVAILABILITY TO THE PUBLIC- The Secretary shall establish procedures for making weighted composite scores calculated under this subsection available to the public in a clear and understandable form, including through its website and the Medicare.gov comparison tool. Such procedures shall ensure that a facility, provider, or physician has the opportunity to review the data that is to be made public with respect to the facility, provider, or physician prior to such data being made public.

                  `(B) CERTIFICATES- The Secretary shall provide certificates to facilities, providers, and physicians who provide services to individuals with end-stage renal disease under this title to display in patient areas. The certificate shall indicate the weighted composite score obtained by the facility, provider, or physician under the quality initiative.

                  `(C) WEB-BASED QUALITY LIST- The Secretary shall establish a web-based quality list for facilities, providers, and physicians who provide items and services to individuals with end-stage renal disease who are enrolled under part B that indicates whether measures were met or not.

            `(12) EVALUATIONS-

                  `(A) EVALUATION BY THE SECRETARY-

                        `(i) RECOGNIZING PART A SAVINGS FROM CONTINUOUS QUALITY IMPROVEMENT INITIATIVE- Not later than January 1, 2010, the Secretary shall evaluate and make recommendations to Congress regarding the feasibility of continuing the quality initiative by funding an annual increase to the composite rate by the ESRD market basket amount under subsection (b)(12)(G) through reduced expenditures under the Federal Hospital Insurance Trust Fund as a result of the quality initiative.

                        `(ii) RECOMMENDATIONS FOR AN ANNUAL UPDATE MECHANISM- Not later than 12 months after the date of enactment of this subsection, the Secretary, acting through the Administrator of the Centers for Medicare & Medicaid Services, shall submit a report to Congress using the data collected as part of the quality initiative to make recommendations about establishing a permanent update mechanism for the composite rate under this section.

                  `(B) EVALUATION BY MEDPAC-

                        `(i) STUDY- The Medicare Payment Advisory Commission shall conduct a study on the advisability and feasibility of making the quality initiative permanent.

                        `(ii) REPORT- Not later than June 1, 2009, the Commission shall submit a report to Congress and the Secretary on the study conducted under clause (i) together with recommendations for such legislation and administrative actions as the Commission considers appropriate, including the need for establishing an annual update mechanism for the composite rate under this section.

                  `(C) EVALUATION BY THE INSTITUTE OF MEDICINE-

                        `(i) IN GENERAL- Not later than 2 years after the date of enactment of this subsection, the Secretary shall enter into an arrangement under which the Institute of Medicine of the National Academy of Sciences (in this section referred to as the `Institute') shall conduct an evaluation of the effectiveness of the quality initiative.

                        `(ii) SCOPE OF REVIEW- The Institute shall consider a variety of perspectives, including the perspectives of facilities, providers, physicians, nurses, other health care professionals, and patients.

                        `(iii) REPORT- Not later than 3 years after the date of enactment of this subsection, the Institute shall submit to the Secretary and to Congress a report on the evaluation conducted under clause (i). Such report shall contain a detailed description of the findings of such evaluation and recommendations for implementing on an ongoing basis the quality initiative.

                        `(iv) AUTHORIZATION OF APPROPRIATIONS- There are authorized to be appropriated such sums as may be necessary for the purpose of conducting the evaluation and preparing the report required by this subparagraph.'.

SEC. 204. EXTENSION OF MEDICARE SECONDARY PAYER.

      (a) Extension-

            (1) IN GENERAL- Section 1862(b)(1)(C) of the Social Security Act (42 U.S.C. 1395y(b)(1)(C)) is amended--

                  (A) in the last sentence, by inserting `, and before January 1, 2008' after `prior to such date)'; and

                  (B) by adding at the end the following new sentence: `Effective for items and services furnished on or after January 1, 2008 (with respect to periods beginning on or after the date that is 42 months prior to such date), clauses (i) and (ii) shall be applied by substituting `42-month' for `12-month' each place it appears in the first sentence.'.

            (2) EFFECTIVE DATE- The amendments made by this subsection shall take effect on the date of enactment of this Act. For purposes of determining an individual's status under section 1862(b)(1)(C) of the Social Security Act (42 U.S.C. 1395y(b)(1)(C)), as amended by paragraph (1), an individual who is within the coordinating period as of the date of enactment of this Act shall have that period extended to the full 42 months described in the last sentence of such section, as added by the amendment made by paragraph (1)(B).

      (b) OIG Study and Report-

            (1) STUDY- The Inspector General of the Department of Health and Human Services shall conduct a study on--

                  (A) the enforcement of the provisions of section 1862(b)(1)(C)(ii) of the Social Security Act (42 U.S.C. 1395y(b)(1)(C)(ii)); and

                  (B) how effective such provisions are at protecting individuals on dialysis from receiving differential treatment by health plans once the individual is diagnosed with end stage renal disease.

            (2) REPORT- Not later than 1 year after the date of enactment of this Act, the Inspector General of the Department of Health and Human Services shall submit to Congress a report on the study conducted under paragraph (1), together with such recommendations as the Inspector General determines appropriate.

[Bill Peckham]

The Bill in the House already has 10 cosponsors - including my Congressman who I saw three times during the last week.

Here is the list - hope you can get your Representative on too:

Rep Bishop, Sanford D., Jr. [GA-2] - 2/27/2007
Rep Butterfield, G. K. [NC-1] - 2/27/2007
Rep Camp, Dave [MI-4] - 2/27/2007
Rep Cummings, Elijah E. [MD-7] - 2/27/2007
Rep Kilpatrick, Carolyn C. [MI-13] - 2/27/2007
Rep McDermott, Jim [WA-7] - 3/1/2007
Rep Reyes, Silvestre [TX-16] - 3/1/2007
Rep Schiff, Adam B. [CA-29] - 3/1/2007
Rep Terry, Lee [NE-2] - 3/1/2007
Rep Wynn, Albert Russell [MD-4] - 2/27/2007

The whole Bill is on http://thomas.loc.gov/ enter the Bill number 1193.

[SierraJim]

  I thnk it is a wonderful service that you are performing here Bill.  I hope everyone reads this and urges their congresspeople to support this important legislation.  It is only through this sort of activity that legislation like this can get passed.  We all need to urge our congresspeople to support this bill.

Jim

[Sluff]

Thanks for your efforts Bill. 

[Bill Peckham]

I should make my role in all of this clear. I do get to go to some renal industry meetings where I am the only dialyzor but you all should understand that to get this Bill introduced and the actual language written is a years long process. This is the third Congress that a Bill like HR 1193 has been introduced and the entire time there are meetings, after meetings; phone calls, upon phone calls. I am not at those meetings or on those phone calls except for one small committee that was looking at one small element of the Bill, the pay for performance continuous quality improvement portion.

There are lobbyist involved. People you've heard of if you follow politics, who once worked in government and now work to advance the issues of their clients either through administrative action (rule change), legislative action (a Bill in Congress) or through appropriations/earmarks (which also move through the legislative process but is a different sort of thing). It is very easy to be cynical about all of this and critical. But I do not know what the alternative is? Once you accept the federal obligation to have a dialysis program there has to be interaction between industry and the government. There is no way to write the laws and the regulations perfectly the first time so the laws are going to need to be revised.

If the revision requires an act of Congress then it's a big deal. To make the change you have to get the attention of people - Representatives and their staffs - who have a chorus of issues demanding their attention. Mostly this all takes time and in the end getting the actual language of a Bill crafted, getting the Bill to say/do what the advocates want it to do requires all of those meetings and telephone calls. The lobbyist organizes and rides herd on the process interacting with Congressional staff to suggest language. All this happens before I get involved.

My job, as I see it, is to put a face on the federal program for the decision makers in Congress. I have a unique view of the industry because I am a successful dialyzor and I am a long time Trustee and incoming Chair of a very respected organization - the Northwest Kidney Centers. That's why I get into these meetings and activities but my presence in the room is incidental to the process. My job comes later when talking to the decision makers in government. They say keep it simple so I have two messages. One, dialysis does work - it's hard, demanding stuff but it can do what it is suppose to do - dialysis can allow a person to live a life they are grateful for and two, the federal government is the dialysis rule setter, the federal government is in charge of how dialysis is delivered in the United States. That is my message, it all flows from that.

My influence totally depends on my ability to persuade. There are many, many changes that I would make to the federal dialysis program if I was put in charge but the fact is no one is in charge. Seriously, these changes to the program are a product of group think consensus building. The Bill HR 1193 does call for the formation of an ESRD Advisory Committee, maybe they could be in charge. It would be good to have someone running the show but truth be told, I don't think I would want the job.

[Debb]

There are many benefits to ESRD patients with this bill, however, passage of it will unfairly shift Medicare costs onto private insurance and cause a "windfall" of profits for the big dialysis chains of approximately 3 billion dollars.  This is America and everyone is entitled to profits for services, but when do the profits being made by big dialysis chains start resulting in better care?  The chains make about $96,959 profit per patient and KT makes 25 million.  35% of the chains profits come through private insurance for the same care as what Medicare pays for. We all know that the big chains are behind these bills so when does the money start equating to better standards of care? What do you think about private insurance reimbursing at medicare rates for the current 30 months + an additional 30 months as proposed by the White House?

[Bill Peckham]

There are many benefits to ESRD patients with this bill, however, passage of it will unfairly shift Medicare costs onto private insurance and cause a "windfall" of profits for the big dialysis chains of approximately 3 billion dollars.  This is America and everyone is entitled to profits for services, but when do the profits being made by big dialysis chains start resulting in better care?  The chains make about $96,959 profit per patient and KT makes 25 million.  35% of the chains profits come through private insurance for the same care as what Medicare pays for. We all know that the big chains are behind these bills so when does the money start equating to better standards of care? What do you think about private insurance reimbursing at medicare rates for the current 30 months + an additional 30 months as proposed by the White House?

If it was up to me I'd write a different Bill; I'm sympathetic with your critique but ...

the President put the private insurance extension in play in his budget (his budget extended the period private insurance is primary in the event of CKD5 from the current 30 months to 60 months) but his budget did not capture those Medicare ESRD program savings to benefit Medicare beneficiaries let alone people with CKD5. HR 1193/S 691 capture those Medicare ESRD program savings for Medicare ESRD program beneficiaries.

Medicare is suppose to pay its own way but the system gets away with paying less. Cost shifting is enshrined in Medicare reimbursement rates, not just in dialysis but in all medical care but in dialysis providers have fewer private payers to cost shift to (as compared to hospitals). 35% of the chains revenue comes from private payers but really all provider profit comes from private payers. And no, this Bill does not address the cost shift cancer in US CKD funding. The current political buzzword or phrase in DC is "Pay Go" meaning new spending has to be off set by savings. This Bill counts about a billion to 1.5 billion dollars in savings (over 10 years) from extending the private pay period to 42 months. The uncertainty is from reckoning how many people that would be, assuming x mortality rate or y program growth.

My beef with the Bill is that I think (and have said directly to Representatives and their staff) that it is a straight fairness issue - Why should ESRD be the only Medicare program without a mechanism to account for inflation? Pay go, shmay go. Why should dialysis have an inflation cut each year? I believe the thinking is that in 2009 the renal community will have vetted a process for pooling part of the update to reward continuous quality improvement. I think we could have advocated for a framework in this Bill that anticipated that opportunity to motivate dialysis quality improvement but legislative strategy is a decision made above my pay grade.

The share price of the renal industry stocks, CEO salaries, reporting unit sales in price per dialyzor all make advocacy harder (and make me grind my teeth) but what can I do? We are tied to Medicare and changes to Medicare take an act of Congress. By creating a carrot, a bonus fund from the annual inflation adjustment, continuous quality improvement offers the opportunity to create levers that should raise quality. It will take ongoing effort; I hope future advocates for improved dialysis care will make good use of these levers - technician certification, CKD4 outreach, education (and some day screening?) - as well as coming up with new and more impactful measures of quality.

I think this Bill is a first step.

[Bill Peckham]

Currently there are 21 members signed on to HR 1193 in the House:

Rep Camp, Dave [MI-4] - 2/27/2007
Rep Bishop, Sanford D., Jr. [GA-2] - 2/27/2007
Rep Wynn, Albert Russell [MD-4] - 2/27/2007
Rep Kilpatrick, Carolyn C. [MI-13] - 2/27/2007
Rep Butterfield, G. K. [NC-1] - 2/27/2007
Rep Cummings, Elijah E. [MD-7] - 2/27/2007
Rep McDermott, Jim [WA-7] - 3/1/2007
Rep Schiff, Adam B. [CA-29] - 3/1/2007
Rep Terry, Lee [NE-2] - 3/1/2007
Rep Reyes, Silvestre [TX-16] - 3/1/2007
Rep Boucher, Rick [VA-9] - 3/9/2007
Rep Berkley, Shelley [NV-1] - 3/9/2007
Rep Grijalva, Raul M. [AZ-7] - 3/9/2007
Rep McNulty, Michael R. [NY-21] - 3/9/2007
Rep Hinchey, Maurice D. [NY-22] - 3/21/2007
Rep Tauscher, Ellen O. [CA-10] - 3/21/2007
Rep McCotter, Thaddeus G. [MI-11] - 3/21/2007
Rep LaTourette, Steven C. [OH-14] - 3/21/2007
Rep Gordon, Bart [TN-6] - 3/21/2007
Rep Burton, Dan [IN-5] - 3/21/2007
Rep Weller, Jerry [IL-11] - 3/21/2007

And I receved an email today that Baird is signing on. I visited a Baird staffer - Marc - when I was in DC so I'll take credit when he is officially listed. In the Senate S 691 has 7 sponsors:

Sen Boxer, Barbara [CA] - 3/6/2007
Sen Chambliss, Saxby [GA] - 3/15/2007
Sen Cochran, Thad [MS] - 3/12/2007
Sen Coleman, Norm [MN] - 3/14/2007
Sen Collins, Susan M. [ME] - 3/12/2007
Sen Lincoln, Blanche L. [AR] - 3/14/2007
Sen Murray, Patty [WA] - 3/8/2007

So I still need to get 7 more Washington State Reps signed up and Senator Cantwell. If you don't see you Representatives drop them an email or give them a call. You can put a name and a face to the US dialysis program. Dialysis does work - hated, dreaded but none the less it is a bridge to tomorrow. Ask them to come visit you on dialysis. I don't think a member of Congress has ever visited the home of someone while they're on dialysis, I should extend the invitation.

[plugger]

Bill,

I wish you and those involved good luck with this bill.  One of my big concerns with this bill is you have Fresenius and davita coming out for tech certification; do you worry that they will try and water down any meaningful tech education?

[Zach]

Bill,

I wish you and those involved good luck with this bill.  One of my big concerns with this bill is you have Fresenius and davita coming out for tech certification; do you worry that they will try and water down any meaningful tech education?

It already has big holes written in it.       

As long as techs are "enrolled" they can work without supervision on the floor.  There seems to be no time limit as to how long a tech can be "enrolled" but not certified, unlike the Georgia State Bill being worked on, which has time limits.

[Bill Peckham]

Here is the relevant language:

SEC. 105. REQUIRED TRAINING FOR PATIENT CARE DIALYSIS TECHNICIANS.

      (a) In General- Section 1881 of the Social Security Act (42 U.S.C. 1395rr) is amended by adding the following new subsection:

      `(h)(1) Except as provided in paragraph (3), beginning January 1, 2009, a provider of services or a renal dialysis facility may not use any individual as a patient care dialysis technician for more than 4 months unless the individual--

            `(A) has completed a training program in the care and treatment of an individual with chronic kidney failure who is undergoing dialysis treatment;

            `(B) has been certified by a nationally recognized certification entity for dialysis technicians; and

            `(C) is competent to provide dialysis-related services.

      `(2) Beginning January 1, 2010, a provider of services or a renal dialysis facility may not use on a temporary, per diem, leased, or on any basis other than as a permanent employee, any individual as a patient care dialysis technician unless the individual meets the requirements described in subparagraphs (A), (B), and (C) of paragraph (1).

      `(3) A provider of services or a renal dialysis facility may permit an individual enrolled in a training program described in paragraph (1)(A) to serve as a patient care dialysis technician while they are so enrolled.

      `(4) For purposes of paragraph (1), if, since the most recent completion by an individual of a training program described in paragraph (1)(A), there has been a period of 24 consecutive months during which the individual has not performed dialysis-related services for monetary compensation, such individual shall be required to complete a new training program or become recertified as described in paragraph (1)(B).

      `(5) A provider of services or a renal dialysis facility shall provide such regular performance review and regular in-service education as assures that individuals serving as patient care dialysis technicians for the provider or facility are competent to perform dialysis-related services.'.



Zach I assume it is the section I highlighted that you are referring to? What language would you suggest? (I haven't read the GA Bill).

I'm not sure this Bill implies they can work indefinitely on the floor without certification. My view of the process is: Congress supplies the bones; CMS supplies the meat. The way this language would be put into practice would depend on a process at CMS or HHS. Now it may be that this process results in an emaciated program which then would require a political solution.

Even if the result of this Bill was an emaciated tech certification program (which is not certain but certainly would be no worse than what we have now. The States can always have requirements higher than Federal minimums) I'd still support the Bill. At least when there is a political solution - some kind of reform of the US health care industry - there will be a placeholder already in the law.

[Zach]

      `(3) A provider of services or a renal dialysis facility may permit an individual enrolled in a training program described in paragraph (1)(A) to serve as a patient care dialysis technician while they are so enrolled.

Zach I assume it is the section I highlighted that you are referring to? What language would you suggest? (I haven't read the GA Bill).

Yes, this is the loophole.  I believe the bill is full of problems.  Who drew up the original bill in the first place?  And if the providers want an annual increase tied to inflation, why not just say it in one or two sentences?

It seems what we need is some disinterested organization to analyze this bill for the people who matter the most, those of us on dialysis.

Is a bad bill better than no bill?  I don't know.

Other than the reimbursement issue, can HHS or CMS write the regulations covering issues the rest of the bill addresses, such as CQI?  Again, I'm ignorant when it comes to passing Bills rather than just writing regulations in the current law.

As far as the Georgia bill:
From:    http://nephronline.com/

SB 57 authorizes the Georgia Board of Nursing, or BON, to certify dialysis technicians by setting minimum standards for their curriculum, instruction and training. The bill defines certification as a valid, current, BON-issued certificate of registration; certification must be renewed every two years and will require completion of a continuing education study. Further, one of the requirements of BON certification will be national certification by an accrediting organization. Regulation of reuse technicians will remain with the Office of Regulatory Services.

Under SB 57, all dialysis technicians will be required to be certified by July 1, 2008; however, dialysis technicians and trainees who were working on or before July 1, 2007, will be grandfathered in by substituting an acknowledgment of competence by the supervising administrative registered professional nurse for the training and national certification requirements otherwise required for BON certification. The bill gives the BON authority to issue a temporary permit to practice to a technician who has completed an approved training curriculum.
The permit will not be renewable and will expire 90 days from issuance.

Technicians may provide dialysis care only under the direct supervision of the registered nurse. The bill defines direct supervision as ?initial and ongoing direction, procedural guidance, and observation and evaluation by a registered professional nurse or physician; and when a patient is being dialyzed, the nurse or physician is in the immediate clinical care area.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Best to get in touch with George Harper in Rome, Georgia for more info on the bill.

[Bill Peckham]

As far as the actual standards that a tech would have to meet or which "nationally recognized certification entity for dialysis technicians" would set the standards I don't know. I tried to find a historic precedent or even a document laying out say the particulars of nurse certification but my Googling came up empty. I'm satisfied with my provider's training process so I have little first hand experience with how the system is broken.

If this was my issue I think I would want to know why CMS can't do it under current law? For instance under existing law CMS could reimburse for six treatments a week or make an inflation adjustment to the composite rate except, in my view, CMS has a reluctance or is unable to challenge the status quo. Are other health care jobs federally licensed?

As far as a disinterested organization the Bill calls for an ESRD Advisory Board who would be charged with picking the CQI measures. As I wrote previously the fact is no one is in charge, other than in a buck stops here sense Congress has the responsibility it assigned itself in 1972.

If saying they want an annual increase tied to inflation in one or two sentences would achieve an annual update it'd ba a done deal. In the 108th Congress there was HR 1784 . It's about as brief as it could be but still when it's written out it feels like it is purposely misleading. I supported 1784 and I believe we'd be better off today had it passed. This was a good bill and it got 64 cosponsors.

SECTION 1. SHORT TITLE.

      This Act may be cited as the `Medicare Renal Dialysis Payment Fairness Act of 2003'.

SEC. 2. UPDATE IN RENAL DIALYSIS COMPOSITE RATE.

      (a) IN GENERAL- The last sentence of section 1881(b)(7) of the Social Security Act (42 U.S.C. 1395rr(b)(7)) is amended--

            (1) by striking `and' before `for such services';

            (2) by inserting `and before January 1, 2004,' after `January 1, 2001,'; and

            (3) by inserting before the period at the end the following: `, and for such services furnished during all subsequent years (beginning with 2004), by the ESRD market basket percentage increase (as defined in paragraph (12)(A) and including any additional factors that may increase costs described in paragraph (12)(B)) above such composite rate payment amounts for such services furnished on December 31 of the previous year'.

      (b) ESRD MARKET BASKET PERCENTAGE INCREASE DEFINED- Section 1881(b) of the Social Security Act (42 U.S.C. 1395rr(b)) is amended by adding at the end the following new paragraph:

      `(12)(A) For purposes of this title, the term `ESRD market basket percentage increase' means, with respect to a calendar year, the percentage (estimated by the Secretary before the beginning of such year) by which--

            `(i) the cost of the mix of goods and services included in the provision of dialysis services (including the costs described in subparagraph (D)) that is determined based on an index of appropriately weighted indicators of changes in wages and prices which are representative of the mix of goods and services included in such dialysis services for the calendar year; exceeds

            `(ii) the cost of such mix of goods and services for the preceding calendar year.

      `(B) In addition to determining the percentage update under subparagraph (A), the Secretary shall also take into account any increase in the costs of furnishing the mix of goods and services described in such subparagraph resulting from--

            `(i) the adoption of scientific and technological innovations used to provide dialysis services;

            `(ii) changes in the manner or method of delivering dialysis services;

            `(iii) productivity improvements in the provision of dialysis services; and

            `(iv) any other relevant factor.

      `(C) The Secretary shall periodically review and update (as necessary) the items and services included in the mix of goods and services used to determine the percentage under subparagraph (A).

      `(D) The costs described in this subparagraph include--

            `(i) labor, including direct patient care costs and administrative labor costs, vacation and holiday pay, payroll taxes, and employee benefits;

            `(ii) other direct costs, including drugs, supplies, and laboratory fees;

            `(iii) overhead, including medical director fees, temporary services, general and administrative costs, interest expenses, and bad debt;

            `(iv) capital, including rent, real estate taxes, depreciation, utilities, repairs, and maintenance; and

            `(v) such other allowable costs as the Secretary may specify.'.

[Bill Peckham]

...please delete - mistake

[Zach]

When I wrote:  "It seems what we need is some disinterested organization to analyze this bill for the people who matter the most, those of us on dialysis," I meant that the bill needs better analysis (what's good, what's bad) than we mortals can provide.  The whole bill, not just CQI.

[Debb]

Zach is right.  Let an independent write the bill based on what the patients know.  I trust the patients not big dialysis chains.

[Bill Peckham]

I've started at least a couple responses to Zack's and now Deb's request for an independent analysis of this Bill and I assume all renal/CKD legislation. What I am left with after going back and forth is, well, Sorry. this is how the "system" works. We, the voters, have incredible opportunities to gather information and try to understand the issues but it takes time. So I agree that it would be great if someone else could be trusted to act in our interests, trusted to do what we'd do if only we had the time to investigate all the angles but that's just not going to happen. Every source is tainted depending on your level of cynicism.

I'll be immodest and say, on paper, I have as close to a an ideal perspective as one could hope. I have spent the last ten years serving on the Board of a non-profit dialysis provider that serves over 1,200 dialyzors (last I checked was still one of the 10 largest US providers), I have business degrees including an accounting degree (I'm no CPA but I can read a balance sheet), I've been on dialysis for 16 years and do not see a transplant in my future, and I work in a completely unrelated industry I draw my pay through the Carpenter's Union. Still I can't make up your mind for you, all I can say is I support this Bill.

As a Trustee I support this Bill because it will allow some predictability in budgeting and service planning. I know that we can not anticipate inflation adjustments until they are law, and we must be good stewards so we plan service levels that in the event are supported by more revenue than was anticipated. As a taxpayer I support the update because I understand inflation happens and I know that according to the Congressional funding rules Medicare is suppose to pay their way and MedPAC, an independent board that looks at Medicare reimbursement indicates adjustments are justified. As for my personal legislative strategy I support this Bill because this inflation update issue takes up a lot of oxygen - other issues are in line but until this inflation update issue is addressed other issues wait their turn. I want more frequent dialysis to be available to every dialyzor. I think the three day a week standard puts too great a burden on the dialyzor, entirely to benefit business efficiency. What this would require I really do not know but I think right now Medicare reimbursement is the first barrier you come to and until this barrier is removed it's hard to see what other barriers remain and politically I don't think "my" Medicare reimbursement issue will be addressed until the inflation update is addressed.

Why do I focus on the reimbursement elements of the Bill? Because that is the cost center and in Congress it is all about cost. This is the sticking point. The tech certification element and the CKD outreach/predialysis education elements call for actions that are less than what NKC is already doing with community support. So yes I support initiatives that will move the country in the direction of NKC's standard of care but I don't think anyone could come up with a scheme that would achieve this in a single piece of legislation.

When I think about the solutions to the inefficiencies and inhumanity of the US health care system I evaluate the solutions in light of our experience with the US ESRD entitlement and what I guess would be the solution's impact on the provision of dialysis in the US. I try to decide if the solution would make dialysis in the rest of the country more or less like dialysis through NKC or improve the economic incentives that govern the industry (or chronic disease care generally). So far all the solutions come up short from the perspective of the people who are sick and there are any number of disinterested organizations and independent entities working on the issue.

[Debb]

A flawed bill is not a good bill.   I appreciate that your path has been a difficult one, please don't give up on what you and all ESRD patients need which is the best care possible at rates that are not going to bankrupt the Medicare funds nor patients and their families.  The for profit dialysis chains are pushing this legislation because it will result in windfall profits for them and my concern is how is this going to result in the best care for patients?  Can we really support passage of a bill that is so heavily financed by these big chains?  Please express your concerns to Congress and Senators over the issues related to the care or lack of it.  These big chains are constantly under investigation, why do you think that is?  It is the patient's that matter the most because the monies are suppose to help support the best care possible.  We cannot give up hope that there will be some bill that will lessen the burden on private insurers and one way to do that is to limit the rates that private insurers have to pay.   

[Bill Peckham]

I'm not sure what the legislation would look like that would cap profits from private payers. Perhaps one way to address your concern would be to say that after the 30th month private payer's charges are capped at 100% of Medicare reimbursement until the 42nd month when Medicare takes over. From my point of view this would maintain the Pay Go offset while, I think, from your point of view it would maintain the revenue status quo.

The question is Is it legal? Is it precedented? Is there an example of the Federal government mandating a maximum rate that a private payer can be charged? I don't know the answer.

[Zach]

I guess I don't see the Bill as positive as you.

Here's more info on current dialysis payments:
http://www.medpac.gov/publications/congressional_reports/Mar07_Ch02c.pdf

[Bill Peckham]

I guess I don't see the Bill as positive as you.

Here's more info on current dialysis payments:
http://www.medpac.gov/publications/congressional_reports/Mar07_Ch02c.pdf

The MedPAC recommondation is the same as every year an inflation update is justified.

What caught your eye Zach?

[Debb]

Bill:

Please listen to Zach.  The truth is the bill is flawed.  You are trying to gain support for a flawed bill.  You are obviously a very intelligent man.  Why don't you get together with the patients and write some inserts rather than rallying for support of a flawed bill?  Who is to say you were not born for this day?  And that your life's experiences brought you here?  Do not be afraid to ask for what you want and even advocate for a bill that will truly help your fellow man?  Come on!  Rally your fellow man and get the bill you need!  Please do not succomb to status quo and please do not advocate for a bill that is going to bankrupt the Medicare funds and funds of the Americans who pay for private insurance.  The private insurance are accounting for the majority of the profits for these big dialysis chains. Is the care for the ESRD patient any better than it was 30 years ago?  Do you think that KT worries about the patient when he is enjoying his $25 million dollar compensation plan?  Why is he whining that they do not have enought money to care for patients?  Why are the patients brining their own tape, blankets and sheets to centers! I know that patients are dependent on the care they receive in these chains and that some patients by speaking out may suffer reprocussions but giving into the status quo is not helping the patients.  In honor of Bill Halcomb who unfortunately had to start this website because he grew weary of being edited by the big dilaysis chains has got to be jumping up in heaven or rolling over in his grave at this bill!

[Bill Peckham]

Hmmm ... I don't feel like you've read what I've written. Zach, I think is intersted in the tech certification element while you seem to be talking about what private payers are charged. I don't feel like anyone has responded to my reasons why supporting the Bill make sense. I think Zach would be closer to his goals vis a vie tech certification in the 111th Congress if this Bill passed, I don't know what exactly you're suggesting Debb. You're leaving me too many blanks to fill in and you should know your comments follows a dozen years of online discussion that I can not help recalling when I read your post. My temptation is to pick up where previous threads have left off but that wouldn't be fair to you. What is your number one issue? Two? Three? ...

If you have an idea about what I should put my energy towards you wouldn't be the first person to have an opinion but you'd have to get in line behind Sue, Christine, Joyce, Charley, Tony, Ray, Debbie ... actually it's a long line.