NN&I is presenting two perspectives on the ESRD bundle cuts the Centers for Medicare & Medicaid Services has proposed, one from a representative of a large dialysis organization and one from a representative of a small dialysis organization. This post was originally written as a letter to the editor in response to Mark E. Neumann's article, “The due diligence on the ESRD payment cut," featured in NN&I's October issue.

It is important to consider the impact the potential cuts would have to the most vulnerable patient population in the country. Dialysis patients are the most at risk from these extreme cuts. When reimbursement for 80% of patients who rely on Medicare is below the cost to provide quality dialysis care there will be unfortunate consequences. Over the past decade reimbursement policy has facilitated expanded access to a dialysis treatment that is not simply a matter of convenience, it is a matter of survival.

(SDO perspective on the bundle cuts: Dialysis patients face fewer options)

The kidney community came together to let their voices be heard, and is the way a democracy is designed to work. DaVita and other providers have earnestly worked with policymakers to communicate the perils the proposed cuts will create. Patients were highly motivated and organically organizing to weigh in on this important policy.

The cut as proposedhas significant consequences on their lives. Patients have a right to know the reasoning and risks behind this policy approach. When we share information with them, we find overwhelmingly that patients desire to advocate for themselves and their quality of life.

We also believe that large dialysis organizations (LDOs) deliver unique and irreplaceable value to the overall kidney care community. While I cannot speak on behalf of all LDOs, I can say that at DaVita, our scale brings extraordinary benefits through superior clinical outcomes, access and quality of care. And we have achieved these benefits while serving the most demographically and geographically diverse patient population in the industry—from extreme rural areas to highly urbanized clinics.

(Despite benefits from the ESRD bundle, stopping the payment 'leakage' is a priority)

Do we have lower costs of care because of our scale? To some degree, yes, but not always, since the costs of operating clinics varies greatly depending on location, structure of ownership, taxes, etc. We also drive down costs for the entire industry which, historically, has led to a lower need for reimbursement and created opportunities for providers to add more services—both of which are good for the system. Organizations that are the best at reducing costs while also leading in quality should be applauded not handicapped, as this proposed cut is poised to do.

(Smoke and mirrors: What is really behind protests over the ESRD bundle payment cut?)

The bottom line is that the proposed rate cut will hurt the patients that get their treatments from all providers large, medium, small, rural, urban and suburban. $216 per treatment is not adequate for nearly all facilities. What is needed is a review of adequacy of payment and for the industry to advocate on behalf of our patients.

We quite simply have availed ourselves of the opportunity to leverage the democratic process to protect access and care for all kidney care patients as a community, regardless of the size of the operation.

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