NN&I - May 2010
National 10 Nephrology News & Issues May 2010www.nephronline.comWith final language on the bundled payment system now expected by mid-summer, renal organizations have been pushing Congress to intervene and request changes before the ink is dry.On March 17, the National Kidney Foundation, Renal Support Network, American Kidney Fund, and Dialysis Patient Citizens sent a letter to Con-gress, asking them to reconsider cer -tain provisions of the payment system. In regard to oral drugs, they said, "The inclusion of oral drugs in the bundle will likely result in increased financial responsibility for beneficiaries, most profoundly for those entitled to low income subsidy under the Medicare prescription drug program and dual-eligible beneficiaries, as well as those patients who may be receiving third party assistance to fully or partially off-set the cost of medications." The groups also recommend that laboratory tests provided in connection with treatment of end-stage renal disease be separately billable, and that a case mix adjustment payment be added for patient race. The patient groups said inclusion of laboratory tests in the bundle "will subject beneficiaries with ESRD to a liability for 20% coinsurance even though other Medicare beneficiaries do not have a coinsurance obligation for lab costs\205The final rule should not increase the financial burden of care on dialysis patients. If the rule does so, dialysis patients would become the only Medicare beneficiaries who are subject to a co-pay for laboratory services." In an email sent March 31, the National Renal Administrators Asso- ciation urged its members to seek con- gressional support for "key issues that could impede our ability to provide quality service" to dialysis patients. "I am urging you to take immediate action to contact your Senators and Repre-sentative to express your con-cerns with the proposed bundled pay-ment system," wrote NRAA president Larry Emerson, "specifically the inclu -sion of oral drugs without intravenous equivalents in the bundle and the 3% reduction in reimbursement during the transition period," which is the time dialysis clinics are given to opt into the new payment system. Renal groups pressure Congress on bundle Compiled by Mark E. NeumannVA proposing to use Medicare rates to cover outpatient dialysis servicesThe Department of Veterans Affairs says it can save 39% in payments to non-VA managed dialysis clinics for patient services, and 75% in lab test payments by switching to Medicare pricing. A proposed rule to change the payment rates for both inpatient and outpatient non-VA services appeared in the Federal Register on February 19; responses to the proposal were due April 19. The proposed rule would set a national payment methodology based on Medicare rates; if approved, the VA estimates it could save $251 million in 2011 for all non-VA services. In addition to payment changes for dialysis and laboratory services, the rule covers ambulatory surgical centers, home health care, and hospice.As part of its payment review, the Department looked at dialysis services and laboratory tests provided to veterans in the first six months of 2008. The VA calculated the impact of paying current non-VA provided dialysis claims for dialysis treatments and for separately payable injectable drugs with current Medicare pricing. An average Medicare composite rate of $157 per dialysis session was used in the analysis, adjusted using Medicare's geographic wage index. "By utiliz-ing Medicare pricing we estimate that VA's outpatient dialy-sis facility expenditures will decrease by 39%," the VA said. To estimate the impact of using Medicare's clinical lab fee schedule, the VA focused on the 100 clinical lab services with the highest aggregate non-VA (purchased care) allowed amounts. "We found that VA paid an average of almost $49 per line item for clinical lab services for the top 100 VA purchased care clinical lab services. Under Medicare pric-ing, the VA would pay an average of $11.47 for these claims. This represents a cost reduction of approximately 75%," the Department wrote in the proposed rule. Berwick picked for CMS leadershipPresident Obama has nominated Donald M. Berwick, MDconsidered a founding father in the field of continu-ous quality improvementto run the Centers for Medicare & Medicaid Services. The agency has been without a perma-nent administrator since October 2006. Berwick is president of the Institute for Healthcare Improvement in Cambridge, Mass. and a clinical professor of pediatrics and health care policy at Harvard Medical School. He is known as an advocate of patient-centered care. "If you are interested in quality, you have to be interested in patient- centeredness," Berwick said in an interview with The New York Times in 2009. "...We have built a system around clini- cians that makes it impossible to customize care the way it needs to be." Berwick's nomination would be subject to Senate confirmation. National_NNI0510_4.indd 10 4/19/10 1:55:13 PM
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