Many of you may have been following the discussions and policy making around Medicare’s “bundling” of dialysis reimbursement.  However, even if you have not it is important to know how the changes in Medicare payments to dialysis clinics will impact both the way patients receive care and how it could increase patients’ financial responsibilities.  On July 24th the Centers for Medicare and Medicaid Services (CMS) released their final rule on how they will pay dialysis providers and what will be included in that bundled payment.  CMS responded favorably to many of the comments DPC and other patient organizations submitted  on their initial proposal.  One such example is CMS created a list of lab tests that will be included in the bundled payment.  Anything outside of this list will be paid for separately – allowing for non-dialysis related labs to be drawn in dialysis facilities. Another favorable inclusion is the delay of including oral medications that do not have an injectable equivalent, such as phosphorous binders,  in the bundle until 2014. This allows CMS to further study how including these medications will impact patients.   Additionally, CMS added a separate payment for home dialysis training to encourage more providers to offer this option to patients.  CMS also made a commitment to develop a monitoring system to track how changes in payment impact clinical practices and patients’ quality care.  

While the final rule is much better for patients than the proposed rule, there are still many areas where patients could have a greater financial responsibility or experience changes in the delivery of their care.  Patients may begin noticing changes to their care and cost sharing as early as January 1, 2011. Every dialysis clinic will be required to fully operate under the new payment system January 1, 2014.  
 

Since there are more services included in this bundled payment for dialysis treatments, some patients may see an increase in the 20 percent cost of their care that Medicare does not pay for.  For example, dialysis related lab tests were previously paid at 100 percent by Medicare, but under the bundle patients will have to pay a portion of the cost for these tests.  In 2014, when all oral medications such as phosphate binders and calcimimetics are included in the bundle, the patient cost share amount will increase again. 

Patients may also experience changes to their prescriptions and to how they receive their medications.  By 2014, facilities will be responsible for purchasing the oral medications used to treat dialysis patients. This means you will either receive these medications in the facility or through the pharmacy the facility has chosen.  If you have not already, you will need to ensure that your facility knows all the medications you are taking – particularly those ordered by your other doctors who treat you for conditions not related to your dialysis care.  This is so your facility can be sure to detect possible interactions between the medications they provide to you and the ones you are already taking.

The bundled payment was passed into law by Congress and was designed to ensure dialysis providers furnish efficient care.  As a result, your physician may wish to change the medication brands you are receiving or change your medication dose.  If this occurs you should keep a journal of any changes in how you feel or any new side effects you may be experiencing and report these to your doctor right away.  If you are concerned about proposed changes to your medications, be sure to discuss these concerns with your doctor. 

To ensure that dialysis providers furnish high quality care, Medicare will also deduct payment from providers who do not achieve Medicare’s quality standards.  This will begin in 2014, and in the first year, dialysis providers will be scored on maintaining patients' hemoglobin levels between  10 g/dl and 12 g/dl and on the percentage of in-center hemodialysis patients who achieve a  urea reduction ration (URR )of 65% or greater (URR is a measure of dialysis adequacy).  In future years, CMS will consider adding additional quality measures related to bone and mineral metabolism, vascular access, patient satisfaction and others. 

CMS also expressed a commitment to monitoring any patient care changes that result from the new payment system and making modifications to the system as necessary.  If you notice changes in your care or copayments please let DPC know.  We will continue to serve as resource to CMS and other policymakers to provide them with the patient perspective on the impact of the bundle and make recommendations as to how they can improve patients’ care and quality of life.