Bipartisan concerns about integrity of Medicare’s ESRD benefit

A group of 17 senators from both sides of the aisle likewise expressed concern about the implementation of the cuts and potential unintended consequences for this group of beneficiaries and providers, telling CMS flatly that the cuts should not result in government failing to cover the cost of care.

The concerns of these lawmakers are well placed. 
Provisions within the American Taxpayer Relief Act (ATRA), passed earlier this year, require CMS to make adjustments to bundled payments for dialysis services. The cuts are meant to reflect decreased utilization for a group of costly medications. In reality, however, these cuts, if not done carefully, could inadvertently undermine the significant advances in quality and outcomes that the bundling program has allowed. 

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Since 2011, bundled payments have allowed Medicare to save money and improve efficiencies by reimbursing providers one lump sum for the host of services they provide to patients. Quality kidney care includes not only the physical process of cleansing toxins from the blood via a dialysis machine when the kidneys cannot, but also a range of ancillary services like nutrition counseling, laboratory analysis, and the administration of certain medications. While “bundling” has proven to be much more efficient than the old way of paying individually for dialysis and the myriad of related medications and services, it leaves little room left to absorb the impending new cuts from ATRA.

The ATRA-related cuts could prove devastating for providers and patients, especially given that Medicare margins are already lower than nearly every other health care sector. The payment reductions could actually force the government to pay dialysis providers less than the cost of the services they provide. Not only is this counter to CMS’ directive to ensure that costs of providing care are covered, it could leave doctors and dialysis facilities holding the bag. In their letter to CMS, the 17 senators emphasized statutory obligations that require the Agency to ensure that Medicare funding for life-sustaining dialysis “should not reduce payments to a level less than the cost of providing care.”

When the amount of Medicare reimbursement falls below the actual cost of providing care, providers could be forced into impossible decisions that directly impact patients. For example, patients may find that they have less flexibility as to when they can receive dialysis treatments.  Or, limitations could be placed on access to nocturnal dialysis, which allows patients to receive treatment overnight and return to their jobs and lives during daytime hours. Facilities may also be forced to reduce the number of staff or staff hours, which would affect patients’ access to the social workers, nurses, and dietitians on whom rely for aspects of their care.   Perhaps most troubling is that facility closures could become an all too real consequence, which could be devastating for rural communities with few, if any, local options.

The cooperation among Republicans and Democrats in the House and Senate on this issue last month leaves me cautiously optimistic that CMS will approach implementing ATRA in manner that ensures patient care is not impacted. I hope CMS will listen to these lawmakers’ concerns, and ensure that changes to ESRD reimbursement are handled thoughtfully with the interests of the nation’s dialysis patients foremost in mind.
 
Kuerbitz is chair of Kidney Care Partners a coalition of more than 30 organizations consisting of patient advocates, dialysis professionals, care providers, researchers and manufacturers, dedicated to working together to improve quality of care for individuals with Chronic Kidney Disease (CKD).