Foremost, CMS concludes by including home training costs in the bundle, there will be “increased flexibility to dialysis centers for greater use of less costly PD and alternative treatment regimens such as nocturnal dialysis, home hemodialysis using compact portable dialysis machines, and shorter but more frequent dialysis sessions.” However, including training in the bundle does not necessarily encourage providers to create more training programs or expand current ones because they will be paid extra whether or not they provide home training. Also, spreading out the training costs among all patients does not appropriately account for the upfront investment providers will need when training patients for home dialysis.
Secondly, CMS states that one reason new patients have higher costs than those who have been on dialysis awhile is that they may be training for home dialysis. However, this is not the case; most patients train for PD or home hemodialysis (HHD) after their first 120 days on dialysis. Therefore, the new patient adjustor CMS has proposed, adding to the payment for patients who are on dialysis for the first 120 days, does not adequately pay for home training either.
Racial Disparities in Care
Many studies have shown and CMS has acknowledged that African Americans utilize more services and may require higher doses of some medications in order to achieve optimal outcomes compared to dialysis patients of other races. While CMS did include an additional payment adjustor that accounts for dialysis patients’ sex, some co-morbidities and body size in determining the dialysis facility payment amount for a particular patient’s treatment, race and ethnicity were not factored in. Without an adjustor for race, facilities will receive less of a payment for treating African Americans and other ethnic minorities who may have higher costs. This could worsen disparities in care. There are many areas of the country that have a higher concentration of African Americans, and thus, there are dialysis facilities that treat mostly African Americans. If clinics cannot afford to provide optimal care to these patients they may be undertreated.
CMS has proposed a new quality incentive program in which anemia management is one of the areas for measurement. The proposed guideline for this measurement states that patients’ hemoglobin should be maintained between 10g/dL and 12g/dL, which also falls in line with the Food and Drug Administration (FDA) recommended range. CMS will issue a separate proposed rule on the quality incentive program designed to monitor quality in dialysis care. In regards to anemia management, CMS is considering implementing a quality measure that may reduce the bundled payment if a patient’s hemoglobin falls below 10 g/dL or above 12g/dL. DPC believes a reduction in payment should only be applied if patients’ hemoglobin falls below 10 g/dL. Anemia is very difficult to treat and maximum flexibility should be allotted to physicians and patients in treating the condition. Since EPO will no longer be separately billable, other less costly means might be utilized to treat patients’ anemia. A quality measure that protects patients from underutilization is necessary since overutilization is already checked by bundling the medication.