NN&I - July 2010
Renal Economics 30 Nephrology News & Issues July 2010Subscribe to our free eNewsletter at www.nephronline.com Introduction The past two years have been a time of anticipation and anxiety in the end-stage renal disease community. Key events have included the enactment of the Medicare Improvement for Patients and Providers Act (MIPPA) in July 2008, which mandated payment reform to the ESRD Program. That included development of a "bundled" prospec-tive payment system (PPS) character -ized by a per-treatment base payment for dialysis, modified by demographic and clinical case-mix adjusters. This "bundle" is expected to cover current composite rate services, ESRD-specific labs, and separately billable injectable medications and supplies. More than a year later, in September 2009, the final proposed rules were released by the Centers for Medicare & Medicaid Services. The agency hosted an open door forum on Oct. 23 and received more than 1,000 comments from stakeholders and interested par -ties during the comment period. The complexities of this proposed rule were succinctly summarized by Tracy Mayne, PhD, in the pages of this journal last year.1 CMS is expected to publish the final rules this month. As an independent, mid-sized dial-ysis provider, we have been actively examining the potential impact of the bundle on our dialysis centers. We start -ed by modeling the financial impact of the "bundle" on one of our dialysis facilities.2,3,4 We found that we stood to lose in excess of $250,000 in Medicare payments annually compared to the current payment system. How can a smaller dialysis provid-er remain financially viable and pro-vide high quality care in this new era? We highlight some of our thoughts, concerns and specific plans as we go forward. 1. Case-mix adjustment Case-mix adjusted payment is man-dated in the proposed PPS, and 18 case-mix adjusters have been identified (see Table 1). Determining the true extent of patient comorbidity in our clinics has been a primary concern. Limitations in communication between and amongst outside providers, especially the hospi-tals and the dialysis clinics, may lead to under-coding of comorbidities and loss of revenue. We expect that addition-al personnel will be needed to chase down medical records. Our strategy: We are considering screening our patients for hemoglobinopathy, mono -clonal gammopathy and HIV. In addi -tion to Hepatitis B, we will seek doc- umentation for these conditions in appropriate patients groups at the time of admission. We also are contem -plating routine periodic screening for occult G.I. bleeding. Social workers and the clinical staff will receive additional training to diagnose alcohol and drug dependence on all existing and new patients, and to offer pre-and post-test HIV counseling. We have also added cardiac arrest, pneumonia, pericardi -tis, myelodysplastic syndrome, multi- ple myeloma, and monoclonal gammo -pathy to the list of comorbid conditions already enumerated in the CMS 2728 form. 2. Medications, IV Review of the breakdown of vari-ous components of the base rate pro-posed by CMS provides an allowance of $71.93 per treatment for separately billable drugs (see Table 2). This allow-ance amounts to 28% of the base rate. Controlling costs of separately billable pharmacy items is essential for survival in the bundled era. Harnessing use of erythropoiesis-stimulating agents (ESAs) is the key to success. Of the $71.93 allowance for drugs, approxi-Preparing for the bundle: One year laterBy Premila Bhat, MD, Wojciech Sokolowski, MD, William Cundiff, JD, MBA, and J. Ganesh Bhat, MD The authors are with Atlantic Dialysis Management Services, LLC, based in Ridgewood, N.Y. Their pre-vious article, "Projected impact of the proposed 'bundled' ESRD payment system on a small dialysis organization," was published in NN&I's June 2009 issue. RenalEconomics_13.indd 30 6/16/10 6:43:25 PM
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