Suzanne Aprile-Forlenza

The proposed Prospective Payment System will be a hardship for independent dialysis providers and impact negatively on the ESRD patient population. The government is cutting cost and expecting improved patient outcomes. There is something wrong with a health care system that places 85-90% of their patients in our facilities and pays less than the cost of providing the care. The patient is the one that will be bear the burden. As a registered nurse working in the dialysis field for the past 25 years, I have seen holistic and preventive care become obsolete. I have witnessed changes in delivery of care that have decreased quality patient care. The statistics show that we haven’t improved the outcomes. Our mortality rates are not improving, if anything we are dialyzing a sicker patient population with a less educated work force. Soon only two dialysis providers will be around to care for our dialysis patients. Our government system places cost cutting above what is best for patient care. Eliminating the patient’s ability to choose their health care provider is not good under any system. Some of the dialysis corporations will cut cost to maintain their profit margin. The cost cutting will be directly related to the employee wages, staff mix and doing more for less. I think is in inappropriate and unfair to now hold dialysis facilities accountable for ESRD Part D oral drugs that are not equivalent to separate billable IV drugs. I think that will affect how medicine is practiced and cause potential unintended clinical consequences. Patients will be affected in the treatment of their disease. There are numerous logistical challenges arising from dialysis facilities becoming responsible for ESRD Part D oral drugs and some very unfair advantages for the large chains which actually own the drug market for certain ESRD drugs. I think secondary hyperparathyroidism will be one disease that we may see clinical consequences in the treatment. This may encourage an increase in cost for surgery for parathyroidectomies instead of conservative treatment with medications. Patients may receive their oral medications from up to three different sites of care (dialysis facility, contracted pharmacy or a local retail pharmacy). This may have a negative impact in coordination of care if there is no centralized care monitoring of drug therapy. Change in access or delivery may lead to non-compliance. I don’t think dialysis facilities should be put in the position of paying for oral pharmaceuticals or coordinating the distribution of those drugs. The government should not be determining medical practice. Good medical practice should be based on professional guidance and not dollar amounts spent by the government. Patients may take the brunt of this decision by only being offered the least expensive medication regardless of its effectiveness. On the flip side of this where is the accountability for patients to take care of themselves. Patients control what that eat and drink which directly affects outcomes. Why do dialysis centers have to take the financial responsibility for the individual patient behaviors by paying for their medications from the treatment cost of the dialysis treatment. The other question related to ESRD Part D drugs, where do PO antibiotics figure in this mix? This may also lead to uncoordinated care and increased cost. Patients are going to be forced to go to another physician than receive holistic care from the nephrologists because of endue burden on the dialysis facility if the nephrologists orders further lab testing and medications. The Case Mix Adjustment has major concerns. Does this lead to discrimination paying based on gender? Where will all the males go? Are centers now going to cherry pick based on the case mix? If a patient is at the neutral point or at the lowest case mix are they going to be by-passed for other candidates? If you are having a case mix adjustment why isn’t race/ethnicity included. There has been documented data that there are differences in treatment based on race. The dialysis treatment is just that a treatment. The co-morbidities each incur their own costs. I find it hard to believe that diabetes did not show statistically significant relationship to composite costs for renal dialysis services. These are the patients that have significant co-morbidities. Access creation in diabetics certainly plays a significant role in cost. There is case mix adjustment for Cardiac Arrest, but what about the patients that has end stage cardiac disease that are well cared for and have not arrested, are they any less complicated? Blood and blood products will also become an issue having them included in the payment bundle. The need for a blood transfusion is not necessarily related to ESRD. State laws vary on where transfusions may be given based on access to blood banks. Blood and blood products should not be included in the bundle. This is not something that is the same across the board from center to center and state to state. The billing and record keeping aspects of dialysis will become considerably more complex which can place a profound burden on dialysis providers for accurate, up to date information, and the ability to easily generate claims and account for earned revenue. I recommend that CMS pays the complete payment for the dialysis treatment and CMS collect the 20% from the patients. This is going to trigger all new negotiations with all the insurance providers. Patients who have commercial insurance may end up having the burden of making up the difference. What happens to the patient that is not Medicare Part D? Will the dialysis centers be incurring the cost from the insurance carriers at a loss while the insurance carriers retain a profit? Why doesn’t the powers to be in the government look at changing their focus to preventive medicine and education. For years dialysis providers have learned how to deliver their services by becoming more cost efficient. For years dialysis providers were forced to increase their standards for quality of care without an increase in their payment system. I think this proposed Prospective Payment System with be a hardship to the renal community. People like me will probably be forced to leave employment in their area of expertise because of the closing of the dialysis centers related to undue financial hardship. Where will the patients go? Who will be willing to treat patients at a financial loss? Our society needs to take some responsibility for its own health and in preventing complications from illness. As a society we need to deal with end of life issues better and change the mind site that everything should be done to maintain life without regard to quality of life to just to delay the inevitable circle of life.