NN&I - July 2010
Renal Economics 32 Nephrology News & Issues July 2010Subscribe to our free eNewsletter at www.nephronline.com new electronic medical records system will monitor hemoglobin levels, iron indices, and ESA dose on a "real time" basis, and give recommendations on how to optimize use of anemia-relat -ed injectable medications. To reduce the incidence of ESA resistance due to inflammation, we have started a pilot project using ultrapure water and instituted protocols to reduce cathe -ters and diagnose and treat occult foot and periodontal infections. In light of recent studies showing the ESA spar -ing effect of higher transferrin satura -tion and ferritin, we switched over to Ferumoxytol as our preferred paren -teral iron. Ferumoxytol also has the advantage of reducing administration costs. 3. Medications, oral Uncertainty remains regarding inclusion of and funding for ESRD-related oral medications. The General Accountability Office has recently rec-ommended that Medicare closely study the impact of inclusion of oral medica-tions on prescribing patterns and out -comes5 and is required to complete a report by March 2011 on the impact by including oral drugs in the bundle. We assume that ESRD-related oral medi-cations are included in the final bun -dle, and roughly $14 per treatment has been allocated for oral medications. Analysis of our charts suggests that this allowance is grossly inadequate, and use of costly medications, such as cinacalcet (Sensipar) and lanthanum carbonate (Fosrenol) may not be finan-cially feasible. Dialysis centers may be forced to scrutinize the oral medica -tion prescription practices of nephrolo -gists and advanced practitioners. Our strategy: We are carefully reviewing the use of medications for the management of CKD-related mineral-bone disorders. It is likely that many dialysis centers will switch patients to oral calcitriol; the use of injectable forms of calcitriol (Calcijex), paricalcitol (Zemplar) and doxercalciferol (Hectorol) may turn out to be the first casualty of the bundled payment system. Sensipar will be clas-sified as a rare resource to be used only when there are no alternatives. Generic calcium acetate (Phoslo) may become the default phosphate binder because of its low cost. Most independent facilities need to review their contracts for injectable medications to get the right pricing. Joining purchasing groups may help lower the acquisition cost of these drugs. If oral drugs are included in the bundle as part of the final rule, we may consider a limited license pharmacy or contracting with a national mail order pharmacy for a fee within the allowance. 4. The laboratory Our understanding of CMS rules is that, in addition to current composite rate lab tests, any lab test ordered by the dialysis facility or an MCP provider will be included in the bundled rate regard-less of whether it is directly relevant to dialysis care. A predicted consequence of this new provision will be limita-tion of tests that can be ordered and sent from the dialysis center, including "courtesy blood draws" requested by other providers. For example, it may not be feasible for the dialysis center to draw coagulation tests ordered by a patient's cardiologist since the center may be burdened with the bill. Our strategy: We are reviewing the legality of sub-mitting such specimens to the lab to be billed under the UPIN of the ordering physician with proper documentation. Since a large majority of nephrologists (MCP physicians) do practice general internal medicine, they might find it dif-ficult to provide non-ESRD related lab-oratory services to their ESRD patients as part of their ongoing continuity of care, e.g. HgbA1C tests for a diabetic 2007 Total Per TxNo. of Medicare Treatments 36,523,791 Proposed Base Rate $252.99 ESA cost $2,014,547,960 $55.16 Vitamin D $402,447,417 $11.02 Iron $165,992,904 $4.54 Other drugs $43,989,058 $1.20 Total Separately Billable (SB) $2,582988,281 $71.93 SB as a % of Base Rate 28%Table 2. Separately billable (SB) costs in relation to the proposed base rate (from CMS-1418-P) RenalEconomics_16.indd 32 6/17/10 3:07:45 PM
You must have JavaScript enabled to view digital editions.
