The Dialysis Bundle and Patients

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Rising Out-of-Pocket Costs

With more services being brought into the Medicare payment bundle, which will be paid for by Medicare Part B, patients may see an increase in their out-of-pocket costs. Medicare Part B does and will continue to pay 80 percent of dialysis patients’ costs, leaving patients to secure secondary insurance coverage or pay the remaining 20 percent of their costs directly. With Medicare increasing the overall amount of money it will pay for patients’ treatments under Part B, the patients’ share of total costs will then also increase.

A portion of this increase will result from including the oral medications that are currently paid for by many patients’ Medicare Part D plans. For example, if a patient qualifies for a low income subsidy (LIS) to help with their prescription drugs, the subsidy will no longer be able to help pay for their drugs that fall within the bundle (the LIS would still cover non-dialysis drugs, however).

Additionally, like all Medicare beneficiaries, dialysis patients’ lab tests are currently paid for in full under Medicare, separate from treatment or medication reimbursement. Under the current proposed rule, lab tests will be moved into the bundle, meaning that they will be covered only at 80 percent and patients or their secondary insurance have to cover the remaining costs. Most ESRD patients either have private insurance or Medicaid and therefore do not have to cover the full 20 percent of dialysis costs out of pocket. Yet for those who do, the additional costs brought on by bundling may pose considerable financial hardship. Furthermore, it is unclear if Medicaid or Medigap programs will be willing to pick up the additional costs of labs and oral medications that they do not have to pay for currently.

Access to Home Dialysis Treatment

The incorporation of home dialysis training costs into the bundle could impact patients’ access to this valued treatment modality. Simply put, under the proposed rule, clinics will receive additional payment for each patient whether they choose to provide home training programs or not. Therefore, whether access to home dialysis will be more widely available to patients will depend on whether dialysis providers believe that creating more home dialysis programs or expanding current programs will be sustainable. In the proposed rule, CMS acknowledged support for home dialysis and proposed to pay peritoneal dialysis (PD) at the same rate as in center hemodialysis, even though its actual costs are less, thus providing an incentive for clinics to expand PD programs. However, they also made a few incorrect assumptions about home dialysis.

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