Each day, nephrologists witness a growing number of pre-ESRD patients at risk, hear the stipulations of increasingly empowered patients and wait for the particulars of an evolving reimbursement environment to become apparent.
While the exact results to changes in reimbursement are still uncertain, and patients continue to engage in their health care decisions and care at a deeper level, one aspect becomes certain.
Change is coming. Most, if not all, changes taking place highlight the need for expanded practices with a greater focus on patients at home.
The Journey Home
Bundled reimbursement requires providers to rethink how to treat their patients and manage their businesses. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) expands the bundle of covered services for End Stage Renal Disease (ESRD) to include medications that, until this point, had been excluded and were reimbursed as separately billable drugs. As providers explore ways to right-size their resources with the best possible treatment for each patient, peritoneal dialysis (PD) offers an effective and viable lever to pull.
MIPPA also provides an education benefit for Medicare recipients diagnosed with Stage 4 Chronic Kidney Disease (CKD) beginning in 2010. This benefit empowers patients to take greater responsibility in their disease and provides them with the necessary information to make informed decisions about the various types of dialysis modalities available. Several studies have shown patients who are objectively informed about dialysis modality options and given free choice more often choose PD home therapy or other self-care dialysis than do uninformed patients.
Rule changes by the Centers for Medicare & Medicaid Services (CMS) to the Conditions for Coverage guidelines for dialysis providers who participate in the Medicare payment system reflect the clinical advances in dialysis therapy and place greater emphasis on quality outcomes, patient empowerment, home as the preferred place of therapy, and administrative processes. This, too, will impact all ESRD facilities participating in the Medicare program.
CMS anticipates that this rule will promote “patient independence and the use of home dialysis whenever appropriate.” Within the document, they state that greater cost savings for Medicare would result with an increase in the use of PD and that the provisions within this rule “will increase the percentage of patients on home dialysis.”
The revised rules specifically state that, “According to USRDS data, the 2004 hemodialysis per patient per year Medicare costs equal $67,733, while the peritoneal per patient per year costs equal $48,796. Approximately 92 percent of U.S. dialysis patients receive in-center hemodialysis. Based on the difference between 2004 hemodialysis and peritoneal costs, savings of as much as $18,937 per patient per year could be obtained with patients opting for peritoneal dialysis. If 5 percent additional patients were to opt for home peritoneal dialysis, which provides added health and quality of life benefits that could account for 15,464 patients. The potential annual savings for these 5 percent additional patients (15,464 x $18,937) could be as much as $295 million.”
