Editor’s Note: We are now a decade and a half into the 21st century. The ESRD Program is cruising past its 50th anniversary and enters this year with some unresolved issues. We sat down––virtually––with Robert Blaser, the Public Policy Director for the Renal Physicians Association (www.renalmd.org) and asked him to give us his annual assessment of the new (Republican) way on Capitol Hill and what impact it might have on kidney care.
Changes along the Beltway
NN&I: Do you see any pluses (or minuses) for renal care under a Republican-controlled Congress this coming year?
Blaser: Certainly. Republicans in general are much more likely to scrutinize and, if possible, roll back what they perceive to be intrusive and over-complicated regulation, and CMS programs such as meaningful use and DFC Five Star Ratings System, among many others, would fit in that category. Also, under this particular Congress, there will be quite an incentive to get legislation passed under Republican control to demonstrate their ability to get things done, and to the extent that we want legislative initiatives such as the Immunosuppressive Drug coverage bill enacted, the chances of that occurring in a working and functional Congress increase (with the understanding that legislation being passed is not necessarily always a good thing).
As for minuses, Democrats in general are much more likely to loosen the purse strings on the federal budget, and thus renal health policy priorities such as kidney disease research funding would be unlikely to flourish under GOP control.
NN&I: Do you think Obamacare was the deathblow for many Democrats who were expected to win, like Louisiana Democratic Sen. Mary Landrieu?
Blaser: Not really. If one puts faith in the post-election exit polling, the economy emerged as the top concern for a plurality of voters (and recalling that there is a sizable percentage of people happy with Obamacare). My take is that the perfect storm of Ebola, ISIS, Russian leader Putin, and the timing of those concerns, i.e., more Obama fatigue than Obamacare, was what lead to the Republican rout.
NN&I: Did the kidney care community lose any advocates as a result of the Republican seat-fest in Congress?
Blaser: Again, not really. The biggest loss is one we knew about, when House Ways and Means Committee chair Dave Camp. R-MI, announced in the spring that he wouldn’t return to Congress. Representative Camp had been a staunch and longtime friend of the kidney disease community, and his departure is a substantial loss. The silver lining, however, may be in that Camp’s replacement as Ways and Means chair, Rep. Paul Ryan, R-WI, being a tax-oriented legislator, is rumored to be handing over control of much of the health care portfolio to W&M Health Subcommittee Chair Kevin Brady, R-TX, who is aware of and sympathetic to the concerns of the kidney community.
Winners and Losers
NN&I: How about a brief recap of 2014? What did you see as victories for the kidney community?
Blaser: The 2014 recap could probably have been written in April, as the SGR Patch/Dialysis Payment Relief/ICD-10-Two Midnight Rule delay law passed on March 31, and this was by far the most significant development of the year. In the regulatory world, the provision in the Medicare fee schedule providing payment parity for hospitalized home dialysis patients and the decision to reverse the policy requiring prior authorizations for Part D drugs prescribed to ESRD patients (two issues championed by RPA, among others) were substantive victories.
NN&I: SGR repeal didn’t quite make it out of the gate. What happened?
Blaser: Some seriously under the radar lobbying and expedient deal making by House and Senate leadership are what derailed the SGR repeal bill. Passage was always going to be a challenge because of the need to find budgetary offsets, but even with that hurdle it was incredibly close to happening. As an advocate for the kidney community, I fully recognize the need and benefit of the dialysis facility payment relief provisions, but as a member of the organized medicine community, the SGR patch was a bitter bill to swallow. And for what it’s worth, it wasn’t just lobbyists for physician groups who were upset about the deal, as there were dozens of legislators from both parties and both chambers of Congress who were enraged about how the SGR patch deal went down.
NN&I: Does Congress get uncomfortable in defining payment incentives for physicians? Do they truly want to past this reform?
Blaser: I think Congress is wary of defining payment incentives for physicians in a technical sense (i.e., how does this actually occur), but this discomfort is offset (pun intended) by their desire for physicians to have some ‘skin in the game’ with regard to SGR repeal. The Hill’s perception is that they are ‘giving’ something to the Part B provider community by repealing the SGR, so the Part B providers should have to give something back in the form of incentives (or rather, penalties for not meeting those incentives). Conceptually this is not completely unreasonable but their (and CMS’) methods thus far for doing so are.
And yes, they truly do want to pass SGR repeal. It is a pain in their derrieres when they have to approve a patch each year, and is a roadblock to enacting other health policy priorities. If the cost were not an issue (and many think it shouldn’t be; this is a completely separate conversation), it would have happened already.
NN&I: The transplant community is still waiting for legislation to extend lifetime immunosuppressive drug coverage. Do you think it has a chance to success this year?
Blaser: It has a chance, but there are so many variables and pieces that have to fall into place that it will be a challenge. Recall that the bill will have to be reintroduced in both legislative chambers in the new, 114th Congress so to some degree the process has to start all over again. That said, there is a lot of existing, in-place support for the initiative that if a Medicare package were to move in 2014, the chances of the immune provision being included are pretty good.
NN&IWhat about The Chronic Kidney Disease Improvement in Research and Treatment Act, a bill that supports improvements in the research, treatment, and care of chronic kidney disease. Any chance we will see that passed in 2015?
Blaser:See previous answer. Actually, the immuno bill is significantly farther along than the CKD legislation in toto in terms of critical mass, but there is a pretty good likelihood of some of the provisions of the CKD bill progressing in a Medicare package if that were to occur.
The Big Picture
NN&I: Do you think the Republicans will attempt to dismantle Obamacare or just change/remove certain pieces of it?
Blaser: I think they’ll pay lip service to dismantling Obamacare and instead wait for the Supreme Court to consider the judicial challenges before doing anything substantive. While some DC types believe that the individual mandate is vulnerable, there is another school of thought that, despite the ridiculous rollout of the website and Gruber-gate, the ACA has been wildly successful in some ways, and undoing benefits such as the ban on pre-existing conditions and coverage until age 26 for adult children will be very difficult politically to roll back.
NN&I: CMS has been introducing some changes to its ACO model. Do you think we will see the renal ACO successful launch in January?
Blaser: I doubt the renal ACO/ESCO launch will occur in January, but I think that it will happen by the end of the first quarter of 2015. CMS/CMMI is committed to the project, and the word on the street is that some proposals they received were of very high quality and worthy of implementation.
All bets are off…
NN&I: Will 2015 be as controversial as the Final Four picks?
Blaser: Like in recent years, it will be a challenging environment in which to pass any legislation in 2015. On the positive side, Republican leadership in both chambers want some achievements, there are issues to be resolved, and possible vehicles through which to do so (debt ceiling negotiations, government spending bills). Negatively, the white noise from macro-level issues, the bitter political divide, and the cutthroat completion for federal funding are massive barriers to progress.
A “Final” Note: In my 2014 column in NN&I, I raised the possibility of the Maryland football team playing in the Rose Bowl. This didn’t happen, but they did play a PAC-12 team (Stanford) in a California bowl game. So, I am thus counting this as an accurate prediction.
Happy New Year.