Where Medicare and the ESRD Program are headed

ATLANTA – The special public policy session assembled by the American Society of Nephrology Kidney Week organizers on Nov. 7 took the packed audience on a roller coaster of viewpoints, defining how kidney patients are faring in the country’s largest health care system.

The program, entitled “The ESRD bundle and QIP: Asking the controversial questions,” was part of the ASN’s annual Christopher R. Blagg Endowed Lecture in Renal Disease and Public Policy. This annual lecture is a shining star for ASN each year, bringing together policy makers and renal organizations to provide a practical look at legislative and economic issues facing the ESRD Program. Dialysis pioneer and historian Chris Blagg, MD, a nephrologist affiliated with the Northwest Kidney Center, is well known for his continuous push for more home dialysis programs in the United States. He is a well deserving honorary for this lecture.

The program’s keynote this year was Jonathan D. Blum, chief deputy administrator for the Centers for Medicare & Medicaid Services. His talk, “Improving standards and quality outcomes: The federal government in action,” was an upbeat review of what Medicare believes is an improving health care system. Blum has held several government positions and has worked at Avalere Health, which provides consulting services to dialysis organizations like the National Renal Administrators Association.

Blum told the overflow crowd that “care is changing for the better,” and at a fairly reasonable price. Medicare has seen historically low increases in total capital costs—almost flat over the last three years, he said. He speculated that people are healthier, taking better care of themselves, and avoiding the hospital, one of the high ticket cost items for Medicare. “Some say people are using fewer services, but Part B (physician payments) remains at similar levels,” said Blum. Costs are coming down in Part A (hospital costs); stabilizing in Part B, and going down in Part D due to the prescribing of generic drugs, he said.

The agency is still trying to tackle a thorny issue: hospital readmissions. From 2007-2010, one out of five Medicare beneficiaries, or about 18%, were sent back to the hospital for readmission.

(Partnering to reduce the high rate of hospital remission for dialysis-dependent patients)

What Medicare struggles with, says Blum, are the variations in the cost of treating patients with a similar diagnosis. “There is no relationship between total cost of care and total quality,” he said. To some degree, the ESRD payment bundle was an attempt to fiscally level the playing field for dialysis care. He made it clear that the intent was to go after the high cost of IV drugs, particularly anemia treatments. Despite drops in EPO use, hemoglobins have leveled off. Another positive benefit? “We are seeing a decline in the rate of stroke, heart failure, and heart attacks since the payment bundle took effect,” said Blum.

The final rule
Blum’s talk was a good segway into a discussion about the pending final rule for the Prospective Payment System and the Quality Incentive Program. Kathleen Lester, who works for Washington, D.C.-based Patten Boggs, a consulting firm that manages the advocacy group Kidney Care Partners, said she expected CMS to hand down the final rule a few days before Thanksgiving. CMS is proposing a 9.4% reduction in the composite rate payment for 2014. She expected one of three possibilities:

The fully proposed $30/treatment cut, likely phased in over three years.
Possible reform of the base composite rate, such as relief from the cumbersome case mix adjusters, and keep the full 9.4% payment cut.
Leave the payment as is, but no increase in the market basket adjustment, which would be 2.6% for 2014.

There are also concerns about the proposed ESRD Quality Incentive Program for 2014. CMS is asking dialysis providers to conduct the CAHPS patient satisfaction survey twice a year, and turn it into a clinical measure. That will be burdensome for providers, she said. There has been a great deal of debate about the hypercalcemia measure. And, Lester said, the Technical Expert Panels that CMS uses to build quality measures need reform. “We need some meaningful change … it is sadly broken,” she said. The renal community needs to see more transparency and understand how comments are reviewed and evaluated.

Ultimately, Lester said, quality of care provided by the renal community should not be solely evaluated by the QIP, citing recent results from the PEAK initiative that saw a 25% drop in mortality among dialysis patients in the first 90 days of dialysis care. -by Mark Neumann

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