Medicare bundling Q&A

1. Can people with kidney disease and those who care about them really help improve the policies that affect kidney disease?

Capitol building Yes! Lawmakers depend on the votes of constituents like you. Medicare leadership must deliver the best possible outcomes for those who have Medicare. The key to successful communication is credibility.

People on dialysis and their care partners know kidney failure best. When you write about what you know and what concerns you, decision makers respond. They may not make the policy choices you want each time, but they have a better chance to make a more informed decision if you share your feedback with them.

Take the time to learn the current issues. Think about how they will affect you and what should be added or taken out. Then share your thoughts with decision-makers.

2. Who makes the rules that affect kidney disease?

Most people on dialysis are covered by Medicare, under the End-Stage Renal Disease (ESRD) Program. Congress oversees Medicare and controls its funding. Congress sometimes passes laws that tell Medicare what it must do. Medicare officials then make rules for how medical services (like dialysis) are covered.

3. How do I know what Medicare policies say about ESRD?

The ESRD Program website has detailed information on all policies that affect ESRD. Medicare updates its policies regularly.

Other websites to find information on policies that affect dialysis include:

4. How does Medicare make policies?

Telephone Before making major policy changes, Medicare publishes a PROPOSED RULE. The proposed rule process invites the public (YOU) to comment. It includes email and mail addresses for you to submit your input. Medicare will take comments for about 60 days. All comments are reviewed by Medicare staff and considered when they craft the final rules.

Once Medicare has reviewed all the public input, they make a final plan and share it. The final plan includes many of the comments submitted and how Medicare changed the plan based on those comments. When a final plan is revealed, it will include the dates when the new plan will take effect.

5. Who are the key decision makers in Medicare that need to hear input?

Medicare has a team of people who work on kidney disease issues. The key decision makers are:

Laurence Wilson
Director, Chronic Care Policy Group
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Develops, evaluates, and reviews regulations, manuals, program guidelines, and instructions for program policies that will be used by contractors and the health care field; Identifies, studies, and recommends changes to Medicare policies to reflect changes in beneficiary health care needs, program objectives, and the health care delivery system.
Dr. Barry Straube
Director and Chief Clinical Officer, Office of Clinical Standards and Quality
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Serves as the focal point for all quality, clinical and medical science issues and policies for the Agency’s programs.

6. What is MIPPA? I keep hearing about it in the news.

MIPPA is the Medicare Improvements for Patient and Providers Act of 2008 (Sections 152 and 153). This new law creates, among other things, a benefit that will pay for some pre-dialysis education starting in 2010. It also requires Medicare to change the way dialysis is paid for, and to develop a new payment system for dialysis. This new payment system is referred to as the “ESRD bundled payment system.”

7. What is the ESRD Bundle?

Since 1983, dialysis has been paid for with a “composite rate.” The composite rate includes the treatment itself and the items needed to do the treatment (heparin, saline, needles, lines, dialysate, staff, some drugs, machine, etc). Other drugs, lab tests, and training for home dialysis could be paid for outside the composite rate. (These were “separately billable.”)

The goal of a “bundle” is to pay one set fee for all items that are routinely used to treat most people on dialysis. The bundle will include things that were separately billable.

This bundle, which will start in 2011, is the most dramatic change in payment for ESRD since Medicare began paying for dialysis in 1973. Congress and Medicare believe that having a bundle will keep dialysis clinics from over-using certain drugs, and will make it easier to pay more for higher quality care.

Summer calendar In June 2008, CMS made a preliminary report to Congress on their research into a bundle. It contains items that might be included in the bundle, and describes some possible quality incentives to encourage more use of home dialysis.

CMS is expected to release a more comprehensive design for the ESRD bundle this summer.

8. What are the key issues expected in the ESRD bundle for Home Dialysis?

Unit of payment: Will the bundle be per treatment, per week, or per month of services? Most in the renal community would prefer payment to be made per treatment.
Scope of services: Exactly which lab tests, drugs, and other services will be included in the bundle? This is not yet clear, but will be included in the Proposed Rule from Medicare expected this summer.
Home training: Training is a resource-intensive, one-time patient course. Home dialysis supporters want training payment to stay outside of the bundle. If included in the bundle, there is a risk that clinics will not want to go to the expense of training patients and caregivers to go home with their dialysis.
More-frequent dialysis: Will Medicare continue to let providers be paid for treatments beyond three per week? Current Medicare policy allows extra treatments to be paid for when there is a medical reason. It is unclear whether this will still be the case under the new bundle.
Home treatments: Congress passed a law that requires Medicare to encourage home dialysis. It is vital that when they create a new bundle, they don’t accidently make it harder for clinics to offer home treatments or for people to choose them.

9. What can I do to help?

Stay tuned! Once Medicare releases the Proposed Rule for the ESRD Bundle, there will only be a short period of time to comment. We will summarize the proposed rule when it is out and tell as many people as possible. That will include a specific CALL TO ACTION with contact information for you to share your input.

If you have questions, please contact:

Bill Peckham
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Rich Berkowitz
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Kathe LeBeau
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Erich Ditschman
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How can I connect with my Senators or Representative?

First, you need to know who your Congressmen are. If you don’t know, you can find your Senators here, and find your Representative here.

Visit their websites to learn about them. Most Representatives and Senators have a website where they post a biography, press releases, and positions on key issues.

Congressional websites have phone numbers and email contact forms. Phone calls are most often taken by a staff member, not by the member of Congress. Ask to speak with the aide who handles Medicare and/or health issues.

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