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Medicare is changing how it pays for dialysis, and this is expected to impact your care. These changes will be phased in beginning in 2011 and will continue through 2014. This brochure is a guide to what you need to know and what you can do to help ensure you continue to receive quality dialysis care during this transition period.

How was dialysis paid for traditionally?
Dialysis treatments, injectable medications received in the clinic, laboratory tests and other items used to treat end stage renal disease (ESRD), also known as kidney failure, are paid for by Medicare Part B for most patients. However, some of these items are billed by the dialysis facility to Medicare as separate items for payment. For example, you may see on your Medicare Summary Notices (statements from Medicare that you receive in the mail at home) that Medicare made one payment for the dialysis treatment you received in the clinic and separate payments for things such as syringes, Epoetin alfa (EPO), vitamin D, and iron.

Medicare Part B pays 80 percent of what the program determines each of these items should cost. Patients are responsible for paying the remaining 20 percent to their dialysis clinic. Some patients pay this money on their own; others have Medicaid, Medigap or other supplemental insurance plans to help pay this portion. This 20 percent is often referred to as your coinsurance responsibility and is listed on your Medicare Summary Notice as the amount you may be billed.

Oral medications you take outside of the clinic that are related to your kidney failure are often paid for by Medicare Part D. Examples of these medications include phosphorus binders and calcimimetics that are used to help control your body’s calcium, phosphorus, and parathyroid hormone levels (PTH).

What is a bundled payment for dialysis?
In a bundled payment, the costs of dialysis treatments, medications, labs and supplies are paid to the clinic by Medicare Part B in one payment rather than a separate payment for each item. Medicare still only pays 80 percent and patients’ coinsurance responsibility (or patient responsibility) is 20 percent.

What is included in the ESRD bundle?

• Beginning in 2011, included in the bundle will be your dialysis treatments, dialysis labs and injectable medications received during treatment like EPO, iron, and vitamin D. Also included will be the pill form of these medications if one exists (most patients who receive their dialysis at home take the pill forms of iron and vitamin D).
   
• Beginning in 2014, all other ESRD-related oral medications that you now receive from your pharmacy will be included in the bundled payment (this includes phosphorus binders and calcimimetics).

How will I be affected?
Copays and Coinsurance: The dollar amount of the Medicare payment to dialysis facilities will include all of the above mentioned items and services whether you use them or not. However, every patient’s cost of care may be different depending on factors like your age, body size, and whether or not you have certain other illnesses. Since the Medicare payment will change, your coinsurance amount may increase, decrease or stay the same. It is expected that the average patient will see a 1.2 percent increase in their copayments because of the inclusion
of laboratory tests that patients did not previously have to pay part of.

Lab Tests: Payment for all lab tests that are related to your dialysis care will be included in the bundle. Labs relating to transplantation will not be included. Since Medicare pays 80 percent of the bundle and you (or your secondary coverage) pay 20 percent, you will pay for labs that you previously did not have to. Lab tests ordered by your physician unrelated to your dialysis will not be a part of the bundle. You should not have a copayment associated with these labs because Medicare will pay the entire cost. However, you may still have the convenience of having other labs drawn in the dialysis facility.

Will I still be able to get the same medications I am currently taking?
Your physician will still be in charge of prescribing medications to you. However, since the dialysis facility will have to provide you with certain medications, there may be specific brands of medications your facility prefers over others. As a result, your physician may suggest you try a different brand, dose or frequency.

How does this impact me if I do dialysis at home or if I’m considering switching to home dialysis?

• All dialysis supplies will be provided to you through your dialysis facility if you are on peritoneal dialysis (PD) or home-hemodialysis (HHD). Previously, some patients worked directly with the supply companies to receive their equipment and supplies.
   
• If you are thinking about switching to a home modality like PD or HHD, you may discover that after the bundle is implemented, more dialysis facilities will offer training on these care options. This is because facilities will now get paid more to provide home training, and it is often less costly for facilities if patients choose to do home dialysis.

What can I do to ensure I receive quality care?

• Monitor your care. It is your right and responsibility to be an active participant in decisions about your health care. You should ask questions about the care you receive. If your doctor suggests you try another medication or would like to change the dose of a medication you are currently on, ask why. Ask him or her to explain any side effects that could result, and to tell you the difference between your current medication and the new one he or she is proposing.
   
• Review your labs. Review your lab results every time you have tests taken, and educate yourself on what your results should be for areas such as hemoglobin, phosphorus, calcium and PTH. Track your progress, compare your current lab results to your previous results and note any changes so you can discuss them with your doctor.
   
• Keep a health journal. Write down what medications you are on and the dose you take. If your prescriptions change, note any differences in how you feel. If you have concerns, talk to your doctor.

Where can I get help if I have concerns about the care I receive?

• First, talk to your physician, nurse, or facility manager at your dialysis clinic. If you cannot get your concerns fully addressed there, you may also contact your local ESRD Network.
   
• To find your local ESRD Network visit www.esrdnetworks.org, or call DPC toll-free at 1-866-877-4242 and we will provide you with the contact information for the ESRD Network that represents you.

At the end of the day, you are the ultimate decision maker about the care you receive. Ensure you ask questions and communicate how you feel to your doctors.

Where can I learn more?
www.dialysispatients.org/esrd-bundle
Toll-free 1.866.877.4242
Email: dpc@dialysispatients.org