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Two sessions during the 2012 NRAA annual meeting addressed legislative and regulatory issues important to the dialysis industry.
Rich Meade of Prime Policy Group told attendees at the National Renal Administrators Association 2012 annual conference that the "lame duck" Congress through January 2013 would mean little activity on the House and Senate floor.
Fixing the Sustainable Growth Rate
One key issue that does need to be resolved is how to fix Medicare’s physician pay. Congress approved a patch to the Sustainable Growth Rate formula last year that governs physician pay, but that expires Jan. 1 and would activate a 27% cut in Medicare physician fees if not addressed. Meade said funding for a temporary or permanent fix would likely have to come from within the Medicare program.
That could include funds from the ESRD Program; a rebasing or recalculating of the bundled payment is due in 2014 as CMS moves all oral medications into the bundle.
Meade said Congress might look to that recalculation for extra funds to supplement physician pay. Other possibilities: eliminate updates for all providers and reduce federal Medicaid match funds to states.
Issues with the ESRD composite rate
Meade said dialysis providers need to keep pressing the case for inequalities in the composite rate, specifically the ongoing struggle of clinics to use case-mix adjusters, and unfunded mandates for projects like CROWNWeb, the CAHPS survey, and other reporting measures from the Quality Incentive Program. Proposed changes to the Prospective Payment System for 2013 also include a reduction in how much bad debt a facility can write off. And, aside from the potential of payment cuts if facilities do not meet the QIP requirements, the anticipated sequestration that calls for deep cuts in Medicare could level an across-the-board 2% reduction on program payments. It is estimated by the Office of Management and Budget that some $11 billion would have to be cut from Medicare.
Gaps, and variations in care for ESRD patients
Participants in the ESRD Program have different views on how dialysis and transplant care is managed, said Straube, a nephrologist who now works for the Marwood Group, a New York-based consulting firm. Patients don't feel treatment is tailored to their needs and medical condition; payers feel the care is uncoordinated and inefficient, and the providers feel payment is inadequate and oversight is too burdensome.
"And those on [Capitol] Hill and in the media tend to say, ‘Why can’t you all do better?" said Straube.
While providers have done a better job with anemia management, dialysis adequacy, all-cause mortality and hospitalizations, and some preventive services, gaps remain in areas like controlling catheter-related infections, managing fluid overload, reducing the risk of cardiovascular disease, patient safety issues, racial, gender, and socioeconomic disparities, and medication compliance, Straube said.
One of the key issues that policy makers look at is the variation in the quality of care across the country. Even though dialysis procedure is technologically standardized from clinic to clinic, "There is a significant geographic variation that exists in the quality and costs of delivering care across the country, even among large providers," said Straube.
Success of the ESRD bundle
The bundled payment system has, for the most part, been successful for clinics and Medicare, Straube said, and there are positive signs that it has led to an increase in home dialysis.
"While hemodialysis treatment billings went up 7.7% between 2009 and 2011, billings for PD went up 17.9%," he noted. But regulators are paying close attention to the drop in ESA use triggered by the bundling of drug payments into the composite rate. Recent data from the Dialysis Outcome Practice Patterns Study shows hemoglobin levels have dropped, and the EPO dose has declined by 23%. Meanwhile, the transfusion rate was higher in 2011 compared to previous years, Straube noted.
CMS has stated that access to care has not been compromised as a result of the bundled payment system, but the agency is being watchful.