Congress has ordered Medicare to revamp the current pricing system. Payments for injectable drugs and lab tests not currently covered by the composite payment are to be "bundled" into it, effective Jan. 1, 2011. Details aren't expected to be released for a few weeks, so the potential impact on dialysis care is difficult to predict.
The open questions:
• Will Medicare keep home dialysis training costs outside the composite payment? Home dialysis advocates fear that rolling such costs into the bundle will discourage centers from offering the home option.
• Will the expanded composite payment be based on what Medicare already pays for dialysis and injectable drugs? That wouldn't result in any savings but could lead to an excessive reduction in the drugs' use, says Bill Peckham, 45, a Seattle dialysis patient and blogger.
• Will Medicare start paying on a weekly or monthly basis, instead of per treatment? Peckham fears that would lead to fewer, not more, treatments.
Straube of CMS emphasizes that a "quality incentive program" will accompany the new payment structure. Instead of paying only on the basis of quantity, he says, Medicare will also begin rewarding dialysis providers on the basis of quality standards, such as how well they manage patients' side effects.
Lazarus, of Fresenius, predicts "a number of (dialysis) units will close because of the bundle. Where are they and who's going to be deprived?" If they're rural, for example, that could greatly impact some patients.
Still, expanding the composite payment is "the right move," Lazarus says. "We have to do something about cost. We have to do something with a system that's out of control. It's a broken system, and we need to fix it."