On Monday July 1, the Centers for Medicare & Medicaid Services (CMS) released the annual proposed rule to update Medicare payment to dialysis providers beginning January 1, 2014 and to modify the Quality Incentive Program (QIP), which reduces reimbursement to providers if they don’t meet specified quality measures. What is most notable about this year’s proposed payment rule (also known as the End-stage Renal Disease Prospective Payment System – ESRD PPS) is that in response to legislation passed by Congress, CMS proposed to cut payment to dialysis providers by 9.4 percent.
The American Taxpayer Relief Act (ATRA) of 2012 required CMS to reduce the payment rate based on the decline in the use of injectable drugs (and their oral equivalents), most notably, erythropoietin stimulating agents (ESA). While ATRA required CMS to reduce the payment rate it did not specify the amount of the reduction, but instead to factor in the decline in the use of these drugs and the current price of the drugs. The National Kidney Foundation (NKF) understands CMS is required by law to reduce the payment rate. However, NKF is concerned about the impact that this large of a cut may have on patient care across the country.
Currently, across all dialysis providers, Medicare profit margins are only 3-4 percent (as estimated by the Medicare Payment Advisory Committee – MEDPAC). Since CMS is proposing a 9.4 percent cut to the base rate for Medicare payments, most providers will have to make considerable changes in how they operate in order to cover the most basic costs of care. NKF is concerned that some providers may not be able to withstand cuts and will have to close facilities and that many others may have to eliminate patient-focused programs, services, and benefits that improve patients’ health and quality of life. Rather than wait and see how dialysis facilities respond to the cuts, we hope that Congress and CMS will engage in a meaningful dialogue with dialysis providers, patient groups, professionals, and others involved in caring for patients to identify ways to reduce the proposed cuts while still complying with the law. You can help us start the dialogue by contacting your Members of Congress and asking them to help stop the cuts.
Also included in this proposed rule are a number of changes to the Medicare ESRD Quality Incentive Program (QIP) that if finalized would impact Medicare payments in 2016. The QIP is a provider penalty program that has been in place since 2012. Dialysis facilities can receive a 0-2 percent reduction in Medicare payments for not meeting the specified quality measures. Each year CMS makes changes to the program to add, remove, or revise quality measures based on new standards of care, or the availability of new data. CMS is proposing to include five new measures that facilities will start being measured on in 2014.
- The percentage of in-center and home dialysis patients with hypercalcemia (a serum calcium level above 10.2%)
- The percentage of hemodialysis (including home) patients with a bloodstream infection
- The percentage of dialysis patients that the facility states have been educated and advised on the risks, benefits and options for anemia treatment
- A requirement to report on iron therapy for all pediatric patients
- A requirement to report certain health related conditions that each dialysis patient has. These conditions include heart disease, hypertension, diabetes, drug and alcohol dependence, tobacco use as well as others.
If finalized, these five measures will be in addition to the six that are currently being measured.
Given the proposed 9.4 percent cut to dialysis payments in 2014, we note that for many facilities implementing strategies to achieve some of these quality measures may be particularly challenging. However, NKF believes quality measurement is an important way to drive improvement in the quality of care patients receive. As we continue to review the proposed regulation, we will consider the impact of the proposed changes to dialysis payment and to the QIP on patient care and provide recommendations to CMS before the agency issues a final rule. As we prepare these recommendations we will call on many of our patient and professional volunteers to weigh in as the experts. Comments are due to CMS August 30, 2013 and we will be sure to share with your our final comment letter and activities around this proposed rule.
Is this going to affect those patients who have no extra coverage? How will co-payments be arranged?
If you don’t have secondary insurance you will still be responsible for paying the 20% that Medicare does not cover. However because the proposed payment rate is less than today’s rate, the portion you will pay is less too. For example, today the Medicare base payment rate for each dialysis treatment is $240.36 (this varies a bit due to factors related to you as an individual as well factors related to the location and size of your facility). Medicare pays 80% of that, which is $192.29 and you are responsible for 20%, which is $48.07. If the proposed reduction is finalized for 2014 the base rate would be $216.95 and you would pay $43.39 so $4.68 less per treatment than you pay today.
-Tonya Saffer, MPH Senior Federal Health Policy Director
Dialysis is no walk in the park. Most Patients I know are already only receiving a monthly check because it is very hard to hold down a job and be at the centers for hours 3 times a week. they stretch their money now , how would they be able to pay for more life sustaining treatments. I was a dialysis pt. now a transplant recepient
Patients would not be expected to pay more for their care as a result of these cuts. In fact facilities are not able to bill Medicare patients more as a way to make up for the cuts.
-Tonya Saffer, MPH Senior Federal Health Policy Director
Fortunately I am still able to work and have a supplemental insurance plan that covers what Medicare doesn’t cover for dialysis treatments, but I worry how clinics may react to these changes and what impact that will have on my ability to work. I already feel like I’m struggling to keep nurses happy because they want to leave work at a certain time and I can’t leave work early 3 days every week to accommodate nurses who want to have a social life in the evening. The systems we have (health care and work schedules) don’t tend to work together very well. When these type changes are contemplated, does congress and the health care industry also consider how employers contribute to well-being of kidney patients? I hear so many people discussing dollars and cents but I never hear anyone mention how we can enable patients to continue being productive citizens.
This is terrible.just terrible..My thoughts r cut the dr. that comes in and talks to patient less then 1 minute .makes 700.00 dollars per patient.hes usually in and out by 1 hour.lots of help.yea right……
My husband has ESRD and gets an extra 1/2 session of dialysis. With the proposed cuts it is entirely possible that the 4th session will be cut or the cost passed along to us, endangering his well-being. Patients and caregivers should not have to worry about these political fights. We have enough to worry about on a daily basis.
This is unacceptable, demand from your congressman and senators that cuts be made elsewhere!
I have been on Dialysis for around 10 years off and on and I have had 5 kidney transplants and I think it is terrible trying to close Dialysis centers when they should make the doctors only come in once a month because when the doctor comes in he just asks how you r doing and then gets paid the big bucks just for 1 min with you. that is not right at all and I bet if Obama was on Dialysis I bet he would not get throwed out because of the unit closing
I was curious to why you’ve had 5 kidney transplants in 10 years? Am I reading that right? My son just received a kidney transplant 3 years ago.
This is wrong, cut,s here should not be made. The care people are receiving is life saving your dealing with people lives. .
I am a dialysis nurse, and former dialysis patient / now grateful transplant recipient. Dialysis is a very difficult balancing act. At the facility I am employed at, we draw labs every two weeks and adjust medications as needed. The nurses along with the doctor, nurse practitioner, and dietician work tirelessly teaching our patients every aspect of care and how best to accomplish good outcomes. With all the teaching we do, there are some patients who are non compliant. Why are we punished for the patients non compliance? There is NEVER a mention of patient compliance! Also, there are patients who try as they might continue with less than optimal outcomes. Why should they be punished? It really disgusts me that politicians make decisions in the medical community that they have absolutely no knowledge of! With proposed cuts will come less staff / less time to accomplish tasks important to performing optimal care. I shudder at the thought of the care patients will then receive!
t”why are we punished for patient’s non compliance?”
typical health care employee above
1.) perpetual complainer
2.) always blaming the patient
I am a PA employed with a nephrology group. I agree that some change needs to occur with the payment schedule for dialysis. I do agree with some patients above that physicians should not be so well compensated for the hour hour they spend in the facility.
Exand the role of mid-levels! RN above, you know well that mid-levels provide great care to ESRD population!
This propposal is dangering the patients LIFE! all to safe a few dollars, I am a husband and caregiver to my wife who is in HD. I am digusted by this cuts.
Reblogged this on kidneystoriesblog.
I started a petition to congress regarding this issue on change.org. We as patients and families need to make out voices heard on this issue. The petition will be delivered to the Senate and House of Representatives. Please take a moment and sign the petition, the more signatures the better! https://www.change.org/petitions/our-life-saving-dialysis-care-is-in-danger-help-me-stop-drastic-cuts-to-medicare.
Thank you so much for your comment! We have a petition online that we’d like your support on as well:
Constituent Services Director, NKF
I have signed your petition on this very important issue. We must continue the fight to makCongress listen and have CMS back down from this!!
I am a dialysis tech and I see how my patents struggle with this illness. Education can only go so far with patients who refuse to comply with treatment. The company I work for are making cut backs in staffing. This makes it hard not only on the staff but patients as well. We only have so many hours in a day to care for our patients the way they deserve and do the other work that Medicare mandates. I feel patient care is not everyone’s main focuse. It’s all about the dollar signs.
Where does the money come from? The taxpayer. Compliance and quality indicators should have been required a long time ago. Two major dialysis companies are on the dow jones stock market index. Believe you me the dollar matters to shareholders!!! Now, who are the shareholders???
Unfortunately , as much as l agree and empathize with all of your above opinions but the truth is – no single solution fits up. For this system to work , all involved including patients and dialysis staff and policies makers need to all do their parts . I know we all blame CMS( Medicare and Medicaid ) for these proposed cuts but the bottom line is , the organization is designed to save cost for the federal government as much as possible
Patients with ESRD do have a huge financial burden with loss of viable employment from the time spent in treating the condition with dialysis but in my experience for every 10 dialysis patients , there are 2 very non compliant patients who will end up using up resources equivalent to the same cost of care for 50-60% of the group. This always skew the actual cost of care for the average dialysis patient .
Many dialysis units lose money due to patients not showing up yet dialysis staff have to be paid for their time . Do you know the water for dialysis and the machines have to be processing for up to 1 hour prior to a patient appointment time ?
l know a patient who only show up for dialysis on average of one time per week but gets admitted to the emergency room 2 times a month for systems relating to lack of adequate dialysis
On average the Medicare payment for her that should have cost less than $1500 for the whole month will end up costing more than $ 20,000 including the cost of admission .
In my opinion , patients should pay out of pocket for dialysis and get full reimbursement from CMS only if they are completely compliant.
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Doen, just how do you expect dialysis patients to be able to afford the upfront cost of dialysis? Seriously? A lot of pts aren’t even able to work.