Remembering the decades of change for RPA, nephrologists

BALTIMORE––In the beginning, there was Section 2991 of Public Law 92-603, passed by Congress on Oct. 30, 1972, extending Medicare coverage to Americans if they had stage five chronic kidney disease.

But the Health Care Financing Administration was not sure how to manage the program. Who would receive funding, and how much? Would all patients be included? A group of nephrologists got together in the fall of 1973 to figure all this out and push for a separate physician payment. A year later, the Renal Physicians Association was officially born. Dues were $15 a year.

John Sadler, MD, who trained at Duke University and practiced at Grady Hospital and Emory University in Atlanta before coming to Baltimore to start the Independent Dialysis Foundation provider group, was the RPA’s first president. “When the legislation passed in 1972. The [American Society of Nephrology] was five years old, and the National Kidney Foundation was just getting off the ground,” Sadler said during a talk at the RPA’s 40^th anniversary meeting here. “We were still in Vietnam.”

While Congressional approval to fund the ESRD Program came about abruptly when Senator Vance Hartke slipped a line into the budget bill with little debate about its implications, Sadler said he and other nephrologists had been lobbying Congress for several years about getting Medicare coverage for people suffering from kidney disease. “God squads” were determining which patients should get treatment because of limited funding and resources. “We told them [Congress] that it was disgraceful that in the wealthiest nation on earth, people were dying from kidney disease because they couldn’t afford to pay for it, “ he said.

When the legislation enacting the ESRD Program finally passed, the Health Care Financing Administration––now called the Centers for Medicare and Medicaid Services––had only six months to write regulations. There was no language in the legislation how dialysis providers should be paid. Sadler and other nephrologists pushed for a monthly, separate payment for physician services. The monthly capitated payment, still in place today, seemed like the right model, but the American Medical Association didn’t like it, said Sadler. “HCFA agreed to setting a global fee for physician care, but said the AMA had to OK it. It took me 15 months. They [AMA] didn’t like capitation." And nephrologists hadn’t learned the art of negotiation with a federal agency. HCFA spent time with nephrologist Christopher Blagg and others at the birthplace of outpatient dialysis in Seattle, and talked with Sadler in Baltimore about how physicians were treating patients. “We were naïve…when they (HCFA) asked us how we did something, we told them. Six months later, it ended up in a regulation,” said Sadler. “That’s not how to put together a program.”

The MCP, defined by HCFA as the “alternative method of payment” for patient care, was enacted in 1974 and was a big victory for the fledging RPA, which itself had no budget ("Everyone had to pay for their own telephone bills, and their travel," said Sadler.) It wasn’t until 1983 when HCFA changed the payment for dialysis provider services and enacted the composite rate. The concept is similar to what Sadler and his RPA colleagues fought for almost 10 years earlier. Today, the payment bundle continues with the Prospective Payment System updates put in place in 2011.

Sadler said the purpose of the RPA, then and now, remains the same: taking care of patients in need. “Remember our patients are our reason for existence; focus on them and we can fulfill our purpose…If you always start with the patient, your reasoning will be good. If you get away from patients, you won't have the credibility," he said.