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August 24, 2010

Dr. Donald Berwick
Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Hubert H. Humphrey Building
Room 314G
200 Independence Avenue, SW
Washington, DC 20201

Re: CMS-1503-P: Medicare Program; Payment Policies under the Physician Fee Schedule and
Other Revisions to Part B for CY 2011; Proposed Rule

Dialysis Patient Citizens (DPC) is pleased to provide comments on the Proposed Rule for Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2011.  As America’s largest dialysis patient organization, DPC is proud to represent over 22,000 pre-dialysis and dialysis patients and their families.  We seek to ensure that the patient’s point of view is heard and considered by policy makers on a wide variety of issues so continued progress may be made in the quality of care and life for dialysis patients.

DPC is pleased with the agency’s continued focus on prevention and improvements in patients’ quality of care.  Specifically, we are happy the agency responded favorably to our request to include Kidney Disease Education (KDE) in the list of approved telehealth services.  This inclusion will afford many more individuals living in rural areas the ability to access this important educational benefit.

We also agree with CMS that home dialysis patients should have access to face to face meetings with their physician (or practitioner) who receives monthly capitation payments (MCP) for providing services to these patients. Regular face to face visits with physicians are important in preventing complications and can lead to early interventions that result in better outcomes for patients.  Yet, there may be circumstances where patients are not able to meet with their physician each month. For example, some patients have stated their difficulty in seeing their physicians monthly because they may already have multiple medical appointments during the course of a month. Having limited transportation options or getting to the physician’s office during times of inclement weather may also hinder a patient’s ability to make a scheduled monthly appointment.

Thankfully, nephrologists, physician assistants, and nurse practitioners also manage patients’ care regularly, outside of face to face meetings, by reviewing patients’ lab results and communicating with patients via phone and email.  While we agree monthly in-person visits are a good standard of care for dialysis patients, patients who report they are feeling well, achieving

optimal outcomes and following prescribed care - which can often be quantified via laboratory data – may not require monthly visits. An unnecessary visit reduces physicians’ abilities to spend more quality time with patients who are experiencing complications or need more support from their physicians.  
Patients undergo extensive training to be able to dialyze at home.  Home dialysis empowers patients to take charge of their own care and work in partnership with their physician and dialysis care team.  Some patients require or may request more support from their physicians than others.  However, we believe all patients should be able to get an appointment to see their physician each month if they would like one.  Physicians who receive MCPs and are not available to patients to meet face to face monthly should be held accountable.
Therefore, we recommend CMS provide for protections to ensure patients who are requesting to see the doctor during the course of the month are afforded this visit, but CMS should also be flexible enough to allow for those patients who are achieving optimal outcomes to make the decision in consultation with their physician as to whether a monthly in-person visit is necessary.  
On behalf of DPC and dialysis patients nationwide, I thank you for the opportunity to submit comments on the proposed changes to MCP requirements and again for supporting greater access to kidney disease education, which will help prevent and delay dialysis for many individuals battling kidney disease.

Sincerely,



 
Chad Lennox
Executive Director