NN&I - July 2010
Renal EconomicsSubscribe to our free eNewsletter at www.nephronline.comJuly 2010 Nephrology News & Issues 41 impact the bundle could have on small and independent providers. Can you describe some of the specific issues you anticipate? Lugo: The wide array of case mix adjus -tors will substantially increase facili -ties' administrative burdens and costs because the data needed to properly bill will be complex. This will put an extra burden on small providers and individually owned dialysis facilities. I cannot imagine a facility billing for dialysis services in the future without having a clinical information system that feeds into the billing system. We are also particularly concerned about the ability of the Medicare Administrative Contractors (MACs) to adequately update and modify their own information systems to properly and timely process claims. Any delay or mistake in reimbursement could cause a facility that is dependent on continu -ing monthly cash flows to shut down if the funds temporarily stop or are inad -equate. For example, even though RCP is a chain, we currently are too small to qualify for one MAC to process all of our claims. Therefore, the possibility that one or several of the MACs that we do use will encounter a reimbursement problem of some sort seems very real. We believe it is appropriate to reduce the number of case mix adjusters from the proposed 18 to a few simple ones. Case mix adjustors should be easy to track, as well as simple to prove. This will prevent placing additional burdens on staff, patients, and physicians with regard to documentation and still result in a more equitable distribution of dol- lars to the facilities that more properly match costs for individual patients. NN&I: Do you foresee any negative ramifications for patients as a result of the proposed legislation? Lugo: A huge area of concern for everyone has been the proposal to include Part D oral drugs in the bun-dle. We feel very strongly that all oral medications should be removed from the proposed bundle. Physicians typi- cally prescribe those medications to patients to be taken with their meals at home and are not maintained or con -trolled by the dialysis facility, nor are they part of a hemodialysis treatment in any way. In order to provide these drugs, facilities would need to have an on-site pharmacy that would comply with state pharmacy licensure requirements or alternatively provide these drugs under arrangement with a licensed pharmacy. An on-site pharmacy is prohibited in 16 states. The financial feasibility of having a pharmacist on-site combined with physical structural and security requirements would make this option prohibitive to the majority of providers. Forcing facilities to sign agreements with licensed pharmacies would create the problem of facilities having to col- lect patient copayments, which would result in significant increased costs to facilities and patients. There is also a serious concern about the adequacy of the funding for oral drugs. Research shows that the current cost data is incomplete and considered unreliable. A proper study on the cost of oral medications for dialysis patients should be completed prior to including these products in the bundle. Deferring inclusion until a later date will allow for the proper accumulation of data, which will in turn protect patients. NN&I: Are there any other items that should be removed from the bundle? Lugo: Labs currently bill CMS for dial -ysis-related lab work done on patients in the clinic. Under the proposal, labs will now bill the dialysis facilities and the facilities will be responsible for all laboratory tests ordered by physicians. Nephrologists often act as primary care physicians for dialysis patients and as such would commonly order tests that are not directly related to a patient's ESRD condition. We would like to see CMS list the ESRD-related labs that should be included in the bundle. The list should include only those tests that are cur -rently included in the composite rate and are clearly furnished for the treat -ment of ESRD. All other non-ESRD labs should be excluded and remain sepa-rately billable by the independent lab. NN&I: Do you see the bundle creating any opportunities for patients and/or providers? Lugo: If the final rule removed the current requirement of providing "medical necessity," then dialysis orga -nizations would be incentivized to edu -cate patients on home therapies. The proposed rule maintains the current "medical necessity" standard for reim -bursement of more than three treat -ments a week. However, home hemo -dialysis patients who self dialyze for a shorter period of time should not be required to medically justify every month a treatment plan which calls for five to six treatments per week. It is critical that CMS differentiate in reim -bursement that there are different types of dialysis treatments for patients. Continuing with the same disad-vantaged reimbursement situation will only inhibit and provide disincentives towards research and technological advancements geared towards improv -ing home therapies. NN&I: Can small- and mid-sized pro-viders survive in the bundled era? Lugo: I sincerely hope that through a very interactive process and consoli- dated efforts, small and independent providers have impressed upon CMS that we rely on them to do what is right and fair on our behalf. Smaller and mid-sized organizations treat 35% of the dialysis patients in the United States: we can not have them close their doors due to underfunding and the inability to handle the additional implementa -tion burden this bundle imposes on them. I am hopeful that CMS will be thoughtful in addressing the issues that affect small and independent providers and in finding sound solutions. RenalEconomics_13.indd 41 6/16/10 6:43:31 PM
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