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December 17, 2009 - A flood of final comments on the proposed CMS bundle of ESRD services

December 8, 2009 - The Home Hemodialysis Work Group, a coalition made up of patients, patient organizations, providers, physicians, and renal organizations has provided its comments (5-page pdf file) regarding CMS 1418-P (The Proposed Rule). The coalition was founded based on a shared interest in maintaining patient access to home dialysis therapies.

December 7, 2009 - Amgen has commissioned a study on the proposed bundle. Report from NephrOnline.
Editor's Note: Ah, yes, the fear approach.

This study was paid for by Amgen — with its ESA monopoly within Medicare — who has the most to lose financially under the bundling proposal.

Both Europe and Japan use less ESAs than the US, yet have better outcomes. However, under current payment regulations, many US dialysis facilities have become dependent on the extra income associated with extra ESA use.

If the bundling proposal tied revenues to improving renal rehabilitation instead of biochemical markers, it would force better and smarter use of taxpayer dollars for ESRD care.


December 3, 2009 - The National Renal Administrators Association has proposed second public review on bundle proposal before 2011, as well as a delay on including oral drugs and lab tests in the bundle. Report from NephrOnline.

November 24, 2009 - What makes a great comment to Medicare? One that is thoughtful and actionable. Blog entry by Bill Peckham from Dialysis from the Sharp End of the Needle.

November 23, 2009 - ESRD bundling: How will this Affect small dialysis providers -- and Patients? A Report From ASN 2009 (Registration required, but free.) Video blog by Berns on Nephrology from Medscape Nephrology.

November 20, 2009 - The expanded dialysis bundle will increase administrative costs. Blog entry by Peter Laird, MD, from Dialysis from the Sharp End of the Needle.

November 17, 2009 - "HR 3962 mandates the inclusion of binders and calcimimetics in the dialysis payment bundle" - blog entry by Bill Peckham from DSEN.

Nov. 9, 2009 - How Bundling Could Affect Nephrology Training - Article from Renal & Urology News.


November 4, 2009 - Two additional articles by activists today:

November 3, 2009 - The Centers for Medicare and Medicaid Services has extended the comment period on the proposed bundle for 30 additional days to Dec. 16th (7-page pdf).

Editor's Note: It appears that CMS's goals of improving outcomes (with 'optimal' instead of 'adequate' treatments) and encouraging home-based dialysis cannot be accomplished through the bundle alone, which must be budget-neutral. To pay for incentives for these improvements in care, CMS is trying to generate savings by including oral meds and labs in the bundle, but these actions appear to cause significant other problems and have many unintended consequences.

In talking with many others at the ASN meeting last week, it became apparent to me that the most powerful financial incentive that CMS has to improve care in the US is to extend the Medicare Secondary Payer (MSP) provision period. If this was changed from the current 30 months to an indefinite period for employed patients, and the healthcare reform bill that prevents dropping healthcare insurance passes, it could revolutionize dialysis care in the US. It would also return the ESRD program back to its original intent, which was to be a renal rehabilitation program.

Today, when Medicare becomes the primary payer automatically at 30 months, dialysis providers can no longer provide optimal care AND make a profit on employed patients. Additionally, it has been estimated that only 15% of patients work after one year on dialysis. Making this MSP change would provide powerful incentives for dialysis providers to help patients keep working, would greatly improve their overall healthcare by finally providing financial incentives (instead of today's real disincentives) to extend their lives beyond 30 months, and would also drive innovations — and renal rehabilitation — that would benefit all patients.


The ESRD PPS public comments are now available as an Excel file or web page. Blog entry by Bill Peckham from DSEN.

November 2, 2009 - The Northwest Kidney Centers of Seattle have put up a Medicare Bundling Proposal resource web page.
In addition, they are holding three forums for patients this week.

October 30, 2009 - The proposed Medicare "bundled" payment system for dialysis is likely to reduce government reimbursements for dialysis units in certain regions of the United States and for some types of facilities, according to research being presented at the American Society of Nephrology's (ASN) 42nd Annual Meeting and Scientific Exposition in San Diego, CA. Press release from ASN.

Article from The Weekly Standard by Stanley Goldfarb, an associate dean of clinical education at the University of Pennsylvania School of Medicine and a nephrologist.

October 27, 2009 - Here are additional prepared statements from the Oct. 23 CMS Town Hall Meeting on the ESRD proposed bundle:
October 26, 2009 - A recording of the Town Hall Meeting held on October 23rd on the proposed ESRD bundle will be available later today by calling (800) 642-1687 and identifying conference ID # 33239635. It will be available for four days only.

A number of the 24 speakers and organizations that read prepared statements has posted these comments online:
An audio recording and transcript of the Oct. 15th Special Open Door Forum will be posted to the Special Open Door Forum website: http://www.cms.hhs.gov/OpenDoo...5_ODF_SpecialODF.asp (See Related Links Inside CMS) and will be accessible for downloading beginning October 25, 2009 and will be available for 30 days.

October 19, 2009 - The Medical Education Institute has released two documents on the proposed ERSD bundle:
NOTE: Comments are due to CMS by 5pm on Monday, November 16.

How to Submit Your Comments:

  1. Online:
    www.regulations.gov/search/Regs/home.html#submitComment?R=0900006480a30c15. You can type in your comments, cut and paste them from a Word document, or upload a file. You'll receive a confirmation email and will be able to view your submitted document.

  2. By regular mail:
    Centers for Medicare & Medicaid Services
    Department of Health & Human Services
    Attention: CMS-1418-P
    P.O. Box 8010, Baltimore, MD 21244-8010.

    Please allow time for mailed comments to arrive before the deadline.

  3. By express or overnight mail:
    Centers for Medicare & Medicaid Services Department of Health & Human Services
    Attention: CMS-1418-P
    Mail Stop C4-26-05
    7500 Security Boulevard
    Baltimore, MD 21244-1850


October 15, 2009 - CMS has posted its presentation for the Oct. 15th Open Door Forum on the ESRD Prospective Payment System Proposed Rule. 41-slide pdf file.


October 9, 2009 - The Centers for Medicare and Medicaid Services is posting public comments on the proposed bundling rule. Related blog entry by Bill Peckham from DSEN.

Here is a commentary from Renal & Urology News: Bundling: A Venture into the Unknown.


October 2, 2009 - The Centers for Medicare and Medicaid Services has announced a Special Open Door Forum on the ESRD Prospective Payment System Proposed Rule Overview to be held on October 15, 2009 from 3:30 PM to 5 PM ET. The call is Conference Call Only. See notice: "**Updated October 1, 2009."

September 29, 2009 - KidneyPublicPolicy101.com goes live.
The Renal Support Network has provided this forum to help people who have CKD, family members, and health care professionals learn about pending reimbursement changes that could potentially impact the way dialysis care is provided. Legislation was passed that has required Centers for Medicaid & Medicare Services (CMS) to Bundle services (treatment, labs, medications) of dialysis care into one payment. CMS has proposed a Rule on what this will look like. The community has 60 days to comment to CMS, after which CMS will review all comments and come back with a Final Rule. RSN encourages the community to get involved and comment to CMS on the risks and benefits.

September 28, 2009 - Nephrology News and Issues has an article on the proposed bundle by the senior director of DaVita Clinical Research. It is a 3-page pdf file that requires the latest version of Adobe Reader.

September 27, 2009 - CMS has put up a web page that is meant to help providers calculate the impact of the proposed bundle. Go to:
http://www.cms.hhs.gov/ESRDPay...517&intNumPerPage=10.

Then click on the CY 2011 Proposed ESRD PPS Facility Level Impact File [ZIP, 988KB] link to open a zip file with three resource files.


September 24, 2009 - NN&I is hosting a free webinar on Oct. 21 dealing with the impact of the bundled payment formula on home dialysis.

September 18, 2009 - The Centers for Medicare and Medicaid Services (CMS) has announced a Town Hall Meeting on the End-Stage Renal Disease (ESRD) Perspective Payment System. It is scheduled for Oct. 23 in Baltimore.

The National Renal Administrators Association has provided a summary of the proposed bundled payment for dialysis. Article from NephrOnline.

The website InsideHealthPolicy.com (subscription only) has a short notice under "Latest News" stating that CMS may not have the legal authority to include oral-only medications in the ESRD Bundling Rule.

The Renal Support Network has converted the 500+ page document from pdf format to WORD.

September 17, 2009 - Medicare's just-released proposed rule for revamping how it pays for treating chronic kidney failure could discourage dialysis centers from training patients to dialyze at home, a University of Washington kidney doctor said Wednesday. Article from USA Today. (Scroll down page to see article.)

September 16, 2009 - The Centers for Medicare and Medicaid Services (CMS) has proposed a new prospective payment system for facilities that provide dialysis services to Medicare beneficiaries who have end-stage renal disease, or ESRD.

First articles from ModernHealthCare.com and Reuters. Summary from Medicare Update.

CMS has posted a press release (dated Sept. 15), two fact sheets (both dated Sept. 15), and an ESRD Payment Overview page. CMS is accepting public comments on the proposed rule until Nov. 16. The new payment system would apply to dialysis services furnished to Medicare beneficiaries on or after January 1, 2011.
"Under the proposed rule, CMS would establish a base bundled payment rate of $198.64 for all of the services related to a dialysis session, including the services in the current composite rate as well as items, including oral drugs that are billed separately."
WARNING: 183-page (pdf file) proposed rule from the Centers for Medicare and Medicaid Services.

See commentary by Bill Peckham from Dialysis from the Sharp End of the Needle. Financial analysis from TheStreet.com.

Editor's Note: My first take on the proposed rule is that it continues the shortsighted focus of seeing quality care as being defined by treatment and biochemical markers instead of the life outcomes that matter to patients. The fact that patients are too often disabled by their "adequate" therapy (physiologically, cognitively, and logistically), become depressed, and then die prematurely, continues to be completely missed and ignored. Mortality rates will likely not significantly improve until we effectively address the psychological and lifestyle burdens of ESRD care that negatively effect quality of life the most.

This message has been edited. Last edited by: Gary Peterson,
 
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