What is “bundling?”
Medicare is changing the way it will pay for dialysis starting in 2011. At that time, Medicare will “bundle” some things into dialysis payments that it pays for separately now, such as drugs and lab tests.
Why is Medicare changing the way it pays for dialysis services?
Congress required Medicare to develop a bundled payment system for dialysis services as part of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) in order to increase efficiency in dialysis care.
How will bundling be different from the way Medicare has paid for dialysis?
Since 1983, Medicare Part B has paid a flat “composite rate” for home dialysis or in-center dialysis and some lab tests. Today, Medicare Part B pays labs for tests that are not in the flat rate. It also pays clinics separately for drugs you receive during dialysis. Medicare Part D pays for other covered drugs you take by mouth at home.
How else might Medicare payment to my dialysis center change as a result of bundling?
The Centers for Medicare and Medicaid Services (CMS) will pay clinics more if they do fewer than 4,000 treatments per year, in order to protect access to care at smaller dialysis centers. This includes rural clinics as well as those that just train and support home patients. Medicare will pay clinics more to care for patients who cost more to treat including those:
However, these changes in Medicare payment for dialysis cannot increase the total amount Medicare spends for dialysis services.
How will this work for individuals who have private insurance through an employer?
If you have an employer group plan as a primary or secondary payer, it will pay based on how your policy is written. If you have questions about how your employer plan will pay for services that Medicare will bundle, talk with a representative from your insurance plan.
Will bundling change the way I get dialysis?
Each dialysis clinic will have to figure out how to operate within the new payment system. No one knows how payment changes will affect people like you, if at all. Changes may not happen right away. Some clinics may choose to change to the new system in January 2011. Others can choose to phase into the new system over the next 3 years. The full impact of bundling may not be known for many years.
One possible change is how anemia is treated with epoetin (EPO) or darbepoetin (DPO). Your nurse may inject this kind of drug under the skin instead of giving it to you by IV, because some data suggest that smaller doses of the drug are required that way. You may get a different kind or amount of iron or vitamin D. You may get iron or Vitamin D by mouth instead of by IV.
How will bundling affect payment for the drugs that I take at home?
Some prescribed drugs you get now by injection or IV at dialysis, your clinic may give you to take by mouth at home. This includes Vitamin D products, iron, and levocarnitine. Medicare will add 49 cents per treatment to your clinic’s bundled payment to cover the cost of these drugs. Medicare Part B will pay for them instead of Medicare Part D.
Medicare planned to include other oral drugs, which do not have an injectable or IV version, in the bundle. However, Medicare decided to delay adding these drugs to the bundle until January 1, 2014. This will provide additional time to evaluate the need to monitor patient conditions treated with oral-only drugs.
Will I still need Medicare Part D or Drug Coverage from an Employer Plan?
You will need to keep your Medicare Part D plan to get drugs that are not in the bundle. This includes drugs for high blood pressure, diabetes, heart disease and other conditions. Unless you are eligible for Medicare Part D’s “full extra help”, you still will have to pay the Medicare Part D premium, co-pays, and coinsurance. If you have an employer plan and the drug coverage under that plan is at least as good as coverage under Medicare Part D, you may not need Part D to cover drugs for high blood pressure, diabetes, heart disease, etc.(See Frequently Asked Questions (FAQs) about Medicare Prescription Drug Coverage (Part D) posted on www.kidneyhealthcovergare.org.)
How will bundling affect me getting my blood drawn and lab tests?
Medicare will pay dialysis clinics for a few extra dialysis-related lab tests under the bundle. You did not have a co-pay for these lab tests previously. Medicare estimates this could increase your out-of-pocket costs 1.2 percent. If you have other insurance, you may not see any change. In fact your total out-of-pocket costs could be lower because of bundling. Medicare will still pay separately for other tests that are not related to dialysis even if your dialysis clinic draws your blood for them. You will not have to pay the Medicare Part B coinsurance for these extra lab tests. Allowing dialysis clinics to do these extra lab tests and paying labs for them may keep you from having to go to another doctor, clinic, or lab, thus saving you time and money. This policy should help your dialysis team stay on top of your total health care needs better.
I am considering home dialysis. How will bundling affect me?
Medicare supports home dialysis. If you start a home training program before your third full month of dialysis, your Medicare coverage can start from your first month of dialysis (if you do in-center dialysis, Medicare does not begin until 3 months after the start of dialysis). Medicare will pay your dialysis clinic much more for your first four months of dialysis no matter whether you do in-center dialysis or you do home training. If you start home training later, Medicare will pay a little more for each training session than it has in the past, if your clinic is paid fully under the bundle. If you go to a clinic that provides only home dialysis training and support, it may get a higher rate for each dialysis treatment as a “low volume” clinic. It is possible that the change in payment for dialysis may spur more clinics to start home training programs. This may allow more patients to do PD or home hemodialysis.
I do peritoneal dialysis (PD), will this affect me?
Medicare payment for a week’s PD will be equal to a week’s hemodialysis. This is how Medicare pays for PD now. Medicare will pay for home patients’ drugs the same way it pays for in-center patients’ drugs. Your clinic will need to decide whether to give you drugs that will be in the bundle by injection, IV or orally. Medicare will pay for bundled drugs under Part B. You will not have to use Part D for drugs you get from your clinic.
How is Medicare protecting me?
New Medicare dialysis regulations that took effect October 14, 2008 offer many patient protections. These include a patient bill of rights, the requirement for an individualized patient plan of care, based upon a comprehensive assessment of the specific patient’s needs, and developed with opportunity for participation by the patient or the patient’s designee. Medicare also has promised it will monitor patient access to dialysis and quality of dialysis care under the new bundled payment system starting January 1, 2011.
What is the Quality Incentive Program (QIP) and how will I know if my dialysis clinic meets those standards?
MIPPA required Medicare to set up a “quality incentive payment” program for dialysis clinics. This will be Medicare’s first “quality incentive program (QIP).” It will start in 2012. Medicare will pay your dialysis clinic up to 2% less per treatment if standards for anemia treatment (hemoglobin levels) and dialysis adequacy (Kt/V) are not met.
When the Quality Incentive Program is working fully, your clinic will get a certificate from the U.S. Department of Health and Human Services (HHS) that it must display in patient areas. The certificate will show your clinic’s total performance score. You will be able to look up other clinics’ scores on Medicare’s Dialysis Facility Compare website at www.medicare.gov/dialysis.
What are the next steps?
Each dialysis clinic may choose, by November 1, 2010, whether to be paid fully at the bundled rate starting January 1, 2011, or to be paid at a “blended” rate that phases in the new rate bundled rate over the next 3 years. Dialysis clinics that do not choose a payment method for 2011, by November 1, 2010, will receive the blended payment from January 1, 2011 until January 1, 2014 when their payment rate will be fully bundled as well. CMS will pay new dialysis facilities, that Medicare certifies on or after January 1, 2011, fully at the bundled payment rate.
How can the National Kidney Foundation help me?
The National Kidney Foundation (NKF) and other organizations and individuals sent comments to CMS on the draft regulation for bundled payment for dialysis services expressing concern about provisions that might harm patients. We also met with CMS staff to discuss our concerns and to provide suggestions. CMS changed some provisions based on comments received. For example, CMS agreed to continue to pay separately for training for home hemodialysis and peritoneal dialysis and for laboratory tests that are not related to dialysis care.
In the Federal Register published August 12, 2010, the Centers for Medicare & Medicaid Services (CMS) published a draft rule for the ESRD Quality Incentive Program (QIP). The NKF submitted comments on this Proposed Rule, calling for inclusion of a quality of life measure. We expect the Final Rule for the QIP will be published in December 2010.