Editor’s Note: The Centers for Medicare & Medicaid Services held a town hall Oct. 23 to discuss the proposed bundled payment rule for the End-Stage Renal Disease Program. The following was the prepared statement from Allen Nissenson, a nephrologist and chief medical officer for DaVita.
Thank you for the opportunity to speak today. I am Allen Nissenson, a nephrologist and chief medical officer for DaVita. I have the privilege of speaking to you on behalf of Kidney Care Partners an organization unique in American healthcare. KCP is the voice of the entire kidney care community—patients and their advocates, dialysis facilities and providers, physicians, nurses, pharmaceutical companies and device manufacturers. Our mission is to ensure that chronic kidney disease patients receive optimal, readily accessible care and lead long, fulfilling, high quality lives.
KCP would like to comment on three areas in the proposed rule of particular concern because if implemented they will seriously harm patients.
First, oral drugs without an IV equivalent.
Patients with kidney failure must have appropriate access to all medications prescribed by their physicians, and physicians should have the autonomy to prescribe the most appropriate drug within classes of medications. These principals will not be possible under the proposed rule. First, patient co-pays related to medications will increase, easily exceeding $800 for a typical patient, will be substantially more for dual-eligible patients and will be a new burden for patients with current low income subsidies. Second, CMS acknowledges that incomplete data was used to determine the current use and cost of oral drugs. Complete and accurate data is essential to getting this right . Finally, KCP questions the legal authority of CMS to include oral drugs with no IV equivalent.
KCP continues to oppose inclusion of oral drugs without an IV equivalent in the bundle until the community’s patient impact, quality, distribution, reimbursement and legal concerns are addressed.
Second, inclusion of all MCP laboratory tests.
ESRD patients are among the sickest of the sick typically with three or more co-morbid conditions. They are treated by nephrologists who often serve as PCP and they see multiple specialists. Laboratory tests unrelated to ESRD are necessary and often ordered by nephrologists in the dialysis facility or in the office, at times at the request of specialists to ensure optimal care coordination, and as a convenience to the patient. This is good for patients, but the proposed rule could seriously undermine this clinical practice by adding administrative burden to the physician’s office and thereby discouraging nephrologists from ordering tests in that setting. KCP has a number of concerns in this area in addition to the disruption of clinical practice: First, under the proposed rule patients again would be forced to begin paying for services previously fully covered—they would have a 20 percent co-pay for laboratory tests, placing yet another burden on this vulnerable population. Second, it is unclear what data was used by CMS to determine funding levels for “all MCP” laboratory tests. Finally, this proposal does not follow Congressional intent- where the phrase “for the treatment of ESRD” was used when referring to bundling lab tests.
KCP urges CMS to define a set of dialysis related tests, accurately determine their frequency, and fully fund them.