THE CENTER FOR DISEASE SERVICES RECENT PROPOSED CUTS TO FUNDING FOR MEDICARE DIALYSIS PATIENTS AND THE MYTH OF SISYPHUS
I was on a conference call this week with the executives from the Dialysis Patient Citizens where we were discussing the CMS’ proposed cuts of payments to dialysis centers and Medicare patients. The speaker mad a very good point that as advocates we must remain consistent. By consistent, he meant that we must be prepared to fight against this issue not just for now, for maybe for a while. That sometimes legislation comes about just not from adjustments made to hot button issues, but from a persistent effort to make your point. You fight not just because it is trendy, but you fight because it is the right thing to do. A fight is more than one round, it is many rounds; it is not a sprint, sometimes it is a marathon. Much like baseball, legislation is 162 games; it is a long season. You must give your best effort, because in the long run there is only one question that really needs to be asked: what is the right thing to do here? It is not a political question; it is not just an ethical question. It is a moral question. It is a lot like corporate responsibility; you look at all sides of an issue and all the viewpoints of the players, then you do what is best for everyone. I have asked myself this question and the answer is very clear to me. The best thing to do for all concerned is to protest, resist and outright fight against such severe cuts to Medicare dialysis patients.
What does Sisyphus have to do with cuts to dialysis centers and Medicare patients? In Greek mythology Sisyphus was a king of Ephedra (now known as Corinth) punished for chronic deceitfulness by being compelled to roll an immense boulder up a hill, only to watch it roll back down, and to repeat this action forever. The idea of course was that the rolling of this rock up to the top of a hill, only to have it roll back down to the bottom would be punishment; an eternal frustration for the former king. In our current climate, legislation can be a lot like that. I don’t have to tell you that on most issuess, the Congress of the United States is divided and deadlocked, and looks to stay that way for a while. A French existentialist, Albert Camus, had another viewpoint of the myth of Sisyphus. The fact that he continued against great odds to roll that rock up and down that hill until he achieved success seemed beautiful. To Camus, the struggle itself was to be admired; success could come, the fight counted!
So why should you encourage your Congressperson and your Senators to fight against these potential cuts? Remember that we only have until August 30th to object. The Center for Medicare and Medicaid Services is the agency responsible for administering Medicare. They were obligated to propose cuts to Medicare funding to dialysis centers as a result of the Fiscal Cliff (The American Taxpayer Relief Act of 2012). Most of the commentators that I read were expecting a 2% cut at the worst. This is a 9.4% cut, almost 10% amounting to an estimated $970 million that goes into effect January 1, 2014. We need to call this to the attention of our legislators, because the CMS will listen to them. Otherwise, they will assume the cuts are not harmful and implement them. The goal here to preserve and protect the care given to dialysis patients, not just at their centers, but for the patients that take dialysis at home as well. We have to ensure all patients have appropriate access to quality care.
THE NUMBERS
There are over 415,000 people with end-stage renal disease receiving dialysis treatments 3 or more times per week to replace kidney function and 82% are Medicare beneficiaries. There are 26 million American Adults that are estimated to have Chronic Kidney Disease (CKD). 1 in 10 people have kidney disease leading to kidney failure, but don’t know it. Their numbers are expected to rise. 2,492,040 are Medicare patients who have CKD, but whose kidneys have not yet failed. 594, 374 Americans do have irreversible kidney failure or End-Stage-Renal-Disease (ESRD), and require either dialysis or a kidney transplant to survive. A person like me that is on dialysis cannot survive long without it; estimates range as low as 5-6 days. Some say you would be lucky to live 2-3 months. Of this group, only 179,631 Americans live with a functioning kidney transplant. 73% of all ESRD patients apply for Medicare to keep themselves alive. The annual cost to Medicare for its ESRD program is $28.4 billion. This amounts to $86, 316 a year Medicare spends on each dialysis patient.
THE REASONS
The reasons we need to act are:
Dialysis centers have already under cuts for funding for their patients; in 2011, the Centers for Medicare & Medicaid Services (CMS) implemented a bundled payment system for dialysis services and built in a 2% reduction in payment. The Sequester further reduced Medicare payments for dialysis by 2% on April 1, 2013.
Continued cuts may deter providers from opening additional facilities at a time when the number of ESRD patients continues to rapidly grow.
The bundled payment system currently does not provide a separate payment for innovation and further cuts will leave little room for new advancements in patient care.
Cuts may result in reduced staffing hours at facilities and a greater burden on staff, which detracts from providing direct patient care.
In January 2013, the Medicare Payment Advisory Committee (MedPAC) finalized a recommendation to maintain the current level of funding for dialysis in 2014. The Chairman noted that the recommendation did not take into account sequestration or recent changes in law, which would reduce payment below MedPAC’s recommendation.
Given that the dialysis bundled payment system is still new, the MedPAC Chairman stated that payment rates should be held constant in order to fully assess the implications of the new payment system on patient care.
The effect the cuts may have on dialysis centers for all dialysis patients is staggering. A proposal to slash reimbursements to kidney dialysis centers in the United States could drive down monies for Fresenius Medical Care AG and Davita Healthcare Partners Inc, two of the world’s leading providers of dialysis services. On July 1, 2013, the day the announcement of the cuts was made by CMS, Fresenius’ stock fell 8.7%. Fresenius receives 30% of its revenue from the CMS. DaVita’s stock not only fell, but it has been written that DaVita would be forced to move towards aggressive cost cutting measure including potential closures. Fresenius operates 2100 dialysis centers in the USA. DaVita has estimated that its 2014 revenues could be so affected by these cuts, that it might cost them $350 million in earnings and lower its earning per share of stock by as much as $2.00. As a result, the bundled payment for ESRD care would be cut from $240.36 per dialysis patient to $216.95, reported Nephrology News & Issues. Altogether, the adjustments would result in a $970 million drop in CMS dialysis payments next year.
A Fresenius spokesman said the company was assessing the 186-page document in which the cuts were proposed.
"Our first impression is that costs and prices have not been adequately taken into account," said the spokesman, who declined to be named. “Proposed cuts of this magnitude simply go too far," said Ron Kuerbitz, chairman of Kidney Care Partners, a prominent coalition of patient advocates, manufacturers, dialysis professionals and care providers.
"We are deeply concerned about the implications for dialysis patients and the sustainability of the Medicare end-stage renal disease system."
Currently, across all dialysis providers, Medicare profit margins are only 3-4 percent (as estimated by the Medicare Payment Advisory Committee – MEDPAC). Since CMS is proposing a 9.4 percent cut to the base rate for Medicare payments, most providers will have to make considerable changes in how they operate in order to cover the most basic costs of care. The National Kidney Foundation is concerned that some providers may not be able to withstand cuts and will have to close facilities and that many others may have to eliminate patient-focused programs, services, and benefits that improve patients’ health and quality of life.
The bottom line appears to be that the Medicare ESRD program may be called into question in which case the people who rely on it to take dialysis would be out in the cold. It could cause layoffs of dialysis personnel, closing of centers, relocating of patients, and instead of life saving dialysis on demand, we would return to rationed dialysis for the few who could afford it and meet the requirements of some dialysis committee. (See “Who Will Die” on You Tube for a viewpoint of what dialysis was like as recently as the 1960’s). . A nearly 10% cut, may adversely affect the quality of care provided by the Medicare ESRD Program. In all likelihood, the proposed cut will endanger the existence of some dialysis units—especially rural, inner-city, and smaller clinics—making it much more difficult for people who must undergo dialysis at least three times a week to receive their care. I take dialysis in Crown Point, Indiana, just 5 mins from my home. If that clinic were to close for lack of Medicare patients, even though I am a private group insurance client, I would be forced to go 3times a week, 4 hours at time wherever they would send me. Where would that be? Chicago? Fort Wayne? Lafayette? South Bend? Indianapolis? What about the trusted relationships we have built up as dialysis patients with our current nurses and techs? They stick 2 needles in my arm every other day; they monitor the amount of fluid they take off and the rate of speed at which they do it. They check my blood pressure and my dry weight ever day because even the smallest of adjustments could lead to headaches, dizziness, nausea, vomiting, heart attacks or even death. As a dialysis patient, you truly place yourself into the medical people’s hands. I am different that every one of the other 40 patients at my center. The nurses and the techs, they know about our subtle differences. They take care of us. They watch out for us. New people in a larger center may not be able to do that; too many patients with too little help and too little time.
If you are on PD dialysis at home, don’t feel too safe. Now if you catheter fails at home you have HD or HD at a center to fall back on. I wonder if this would change too. Food for thought?
ACTION YOU CAN TAKE
There are several things that you can do that would help. First, you have to voice your concerns to your Congressperson and Senators. All of the major organizations that I belong to including the DPC have recommended that we contact our politicians as they CMS might be more inclined to listen to them as well as to us. There are several ways to do that.
If you want to go online and take action you can send a customized letter through the DPC at this site: http://tinyurl.com/qet4zj2. It is a form letter that you can add your personal story to.
If you prefer to call your Congressperson or Senators’ offices here is a link for that: http://tinurl.com/n46cfrp. The DPC provide some sample points to make and they give you the numbers.
If you want to sign a petition online, here is a link for that:
https://www.change.org/petitions/center-for-medicaid-and-medicare-services-cms-withdraw-the-proposed-cuts-to-dialysis-centers-and-esrd-patients
If you want to write a letter to your Congressperson/Senator here is a link for names, and addresses to find them: http://whoismyrepresentative.com/
Here are some ideas for what you could include in a letter:
My name is [YOUR NAME]. I am a dialysis patient/caregiver/spouse/relative and I live in [CITY, TOWN NAME]
I am writing to you to express my outrage over the proposed Medicare cut for my dialysis care by over 9%
I rely on Medicare for my dialysis treatments and would not be alive today without it
These cuts are dangerous and threaten my care. I need my dialysis facility to be able to stay open and have enough staff
Please do what you can to change these terrible cuts to dialysis today
Make sure to tell your friends and family to do the same!
Here is a form letter:
CMS’ Proposed Cuts to the Medicare ESRD Program Put Access to Dialysis Care at Serious Risk
As your constituent and an advocate for kidney care, I am writing to express my very serious concern about and opposition to the Centers for Medicare and Medicaid Services’ (CMS) proposal to cut Medicare’s end-stage renal disease program by nearly 10 percent, or approximately $30 out of the current reimbursement rate of $246 per dialysis session. A cut of this magnitude would be devastating. If this proposed rule is finalized, it will have damaging effects on people with kidney failure.
More than 400,000 Americans have irreversible kidney failure. Approximately 85 percent of these individuals rely on Medicare for their dialysis care.
As you are aware, Medicare-covered dialysis has been subject to numerous reimbursement reductions in recent years. Additional cuts of the scope that CMS proposes could reduce access to care or undermine quality.
I urge you to ensure that Medicare reimbursement for dialysis is sufficient to cover the cost of care. I also urge you to emphasize this point to CMS.
James W. Myers, III
If you want to write to the CMS directly:
WHERE TO CONTACT THE CMS: You may submit comments in one of four ways (please choose only one of the ways
listed):
1. Electronically. You may submit electronic comments on this regulation to http://www.regulations.gov/. Follow the “Submit a comment" instructions.
2. By regular mail. You may mail written comments to the following address ONLY:
Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
Attention: CMS-1526-P,
P.O. Box 8010,
Baltimore, MD 21244-8010.
Please allow sufficient time for mailed comments to be received before the close of the comment period.
3. By express or overnight mail. You may send written comments to the following
address ONLY:
Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
Attention: CMS-1526-P,
Mail Stop C4-26-05,
7500 Security Boulevard,
Baltimore, MD 21244-1850.
4. By hand or courier. Alternatively, you may deliver (by hand or courier) your written comments ONLY to the following addresses prior to the close of the comment period:
a. For delivery in Washington, DC—
CMS-1526-P 3
Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
Room 445-G, Hubert H. Humphrey Building,
200 Independence Avenue, SW.,
Washington, DC 20201
(Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without Federal government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp- in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.)
b. For delivery in Baltimore, MD—
Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
7500 Security Boulevard,
Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address, call telephone number (410) 786-9994 in advance to schedule your arrival with one of our staff members.
Comments erroneously mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period.
For information on viewing public comments, see the beginning of the “SUPPLEMENTARY INFORMATION" section.
FOR FURTHER INFORMATION CONTACT:
Michelle Cruse, (410) 786-7540, for issues related to the ESRD PPS.
CMS-1526-P 4
Stephanie Frilling, (410) 786-4507, for issues related to the ESRD PPS wage index, home dialysis training, and the delay in payment for oral-only drugs under the ESRD PPS.
Heidi Oumarou, (410) 786-7942, for issues related to the ESRD market basket.
Anita Segar, (410) 786-4614, for issues related to the ESRD QIP.
Sandhya Gilkerson, (410) 786-4085, for issues related to the clarification of the grandfathering
provision related to the 3-year MLR for DME.
Anita Greenberg (410) 786-4601, for issues related to the clarification of the definition of routinely purchased DME.
Christopher Molling (410) 786-6399, for issues related to DMEPOS technical amendments and corrections.
Hafsa Vahora, (410) 786-7899, for issues related to the implementation of budget neutral fee schedules for splints and casts, and IOLs inserted in a physician’s office.
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