realdialysisethics
Joined: 06 Jan 2003
Posts: 41
Posted: Tue Aug 12, 2003 11:35 am Post subject: Meeting with CMS
--------------------------------------------------------------------------------
<
>I would like to take this opportunity to come out from behind my user name and introduce myself. Most of you know me as "Sick of it" but my name is KC White. An eight year veteran of dialysis and a two year survivor of a kidney transplant. Additionally, I have served on the board of directors for DEO, 1 and a half years and I was one of the first patients to call Arlene from the fledgling web site.<
><
>It was my honor to be part of DEO's historic meeting yesterday with the Centers for Medicare & Medicaid Services (CMS) where we presented patients rights and the current concerns of the dialysis community. Other DEO participants presented key information on improving quality outcomes for dialysis patients. We feel that the meeting went well, and were told that in the future they would be willing to work with us towards improving the dialysis patient's condition. Additionally, a future meeting was promised to compare ideas on how to change and improve dialysis in today's market.<
><
>Within the sprit of our meeting, we were notified today of the following payment guidelines that were released for public review. This is a small step towards an improved patients quality of care.<
><
>Thanks to all the DEO people that participated in person or by supporting information for our meeting yesterday. We will have the complete story tomorrow. <
><
><
>The payment guidelines are as follows: (for payment charts go to CMS website and download them)<
><
><
>5. Create G codes for dialysis patient seeing the doctor.<
>We have reviewed our current payment policy for the monthly dialysis capitation, CPT codes 90918 through 90921 in response to concerns that have been raised over whether our payment policy is consistent with current medical practice.<
>Specifically, we understand that physician involvement in dialysis for end stage renal disease (ESRD) varies based on a patient?s condition, response to dialysis, and comorbidities. A physician involvement for a single patient may also vary from month to month. It is our intent to ensure that beneficiaries with ESRD receive the highest quality dialysis care available and that physician involvement in dialysis for ESRD patients is appropriate and consistent with the needs of the patient in any month. <
>Observers of the quality of care for dialysis patients have noted that some dialysis patients may benefit from being evaluated by their physician frequently. A recent international comparison study suggested that longer physician-patient contact time in hemodialysis facilities was associated with lower mortality risk.<
>To align the payment incentives with the frequency of the physician personally evaluating the dialysis patient, we are proposing to make CPT codes 90918, 90919, 90920, 90921 invalid for Medicare and to create G codes. We are proposing to create 3 new G codes in place of each CPT code with higher payments associated with providing more visits within each month to an ESRD patient. Under our proposal, there will be separate codes when the physician provides 1 visit per month, 2-3 visits per month and 4 or more visits per month. The code for 1 visit per month will have the lowest payment while a higher payment will be provided for 2 to 3 visits per month and the highest payment for 4 or more visits per month. Our methodology for determining payment is described below. These new codes will be reported once per month for services performed in an outpatient setting and related to the patient?s ESRD. These physician services will continue to include the establishment of a dialyzing cycle, outpatient evaluation and management of the dialysis visits, telephone calls, and patient management, provided during a full month. These codes would not be used if a hospitalization occurred during the month.<
><
>GXXX5 ? End Stage Renal Disease (ESRD) related services per full month, for patients under 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month.<
><
>GXXX6 - End Stage Renal Disease (ESRD) related services per full month, for patients under 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2 or 3 face-to-face physician visits per month.<
><
>GXXX7- End Stage Renal Disease (ESRD) related services per full month, for patients under 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month.<
><
>GXXX8 ? End Stage Renal Disease (ESRD) related services per full month, for patients between 2 and 11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month.<
><
>GXXX9 - End Stage Renal Disease (ESRD) related services per full month, for patients between 2 and 11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2 or 3 face-to-face physician visits per month.<
><
>GXX10 - End Stage Renal Disease (ESRD) related services per full month, for patients between 2 and 11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month. <
><
>GXX11 ? End Stage Renal Disease (ESRD) related services per full month, for patients between 12 and 19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month.<
><
>GXX12 - End Stage Renal Disease (ESRD) related services per full month, for patients between 12 and 19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2 or 3 face-to-face physician visits per month.<
><
>GXX13 - End Stage Renal Disease (ESRD) related services per full month, for patients between 12 and 19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month.<
><
>GXX14 ? End Stage Renal Disease (ESRD) related services per full month, for patients 20 years of age and over; with 4 or more face-to-face physician visits per month.<
><
>GXX15 - End Stage Renal Disease (ESRD) related services per full month, for patients 20 years of age and over; with 2 or 3 face-to-face physician visits per month.<
><
>GXX16 - End Stage Renal Disease (ESRD) related services per full month, for patients 20 years of age and over; with 1 face-to-face physician visit per month.<
>We are assuming that most physicians will provide 4 or more visits to their ESRD patients and a small proportion will provide 2-3 visits or only 1 visit per month. Using these assumptions and Medicare utilization data from 2002, we developed relative value units for the new G codes that will make the Medicare?s aggregate payments for ESRD related services under the physician fee schedule approximately equal to current payments that are occurring using procedure codes 90918 to 90921. Relative to our current payments, we are proposing to lower payment when the physician provides 1 visit per month or 2-3 visits per month. Since we are proposing to lower payment if the physician provides fewer than 4 visits per month, in order to maintain the same aggregate payments for ESRD related services, we are proposing to increase payment if the physician provides 4 or more visits per month. Using these assumptions, the proposed work, practice expense and malpractice RVUs for procedure codes GXXX5 through GXXX16 are shown below: <
> <
><
>Table 4<
><
>Code <
>Physician<
>Work <
>Practice Expense <
>Malpractice<
>GXXX5 12.92 8.70 0.60<
>GXXX6 5.19 3.49 0.24<
>GXXX7 3.39 2.29 0.16<
>GXXX8 9.91 4.86 0.43<
>GXXX9 3.55 1.74 0.15<
>GXX10 2.32 1.14 0.10<
>GXX11 8.47
4.54 0.35<
>GXX12 3.14 1.68 0.13<
>GXX13 2.05 1.10 0.08<
>GXX14 5.16 2.94 0.22<
>GXX15 1.94 1.10 0.08<
>GXX16 1.27 0.73 0.06<
><
>We believe that stratifying payment amounts by physician face-to-face involvement would be an improvement over the current method, but still may not be optimal to foster improved outcomes.<
><
>Both the Institute of Medicine and Medicare Payment Advisory Commission (MedPAC) have advocated an increased role for CMS in encouraging improved quality outcomes. In their June 2003 Report to Congress (Variation and Innovation in Medicare), MedPAC recommended ?the Secretary should conduct demonstrations to evaluate provider payment differentials and structures that reward and improve quality.?<
>We responded to this call by increasing the focus of our Quality Improvement Organizations (formerly called Peer Review Organizations) and ESRD Networks on developing quality measures and also performing or assisting providers with the performance of quality improvement activities. We have also implemented initiatives to address the quality of care provided in various settings. These include: the Home Health Quality Initiative; the Hospital Quality Initiative; the Nursing Home Quality Initiative; the Home Health Quality Initiative and Doctors Office Quality Project (see cms.hhs.gov/quality/ for more information). <
>Additionally, the we have developed various demonstration projects that provide incentives to improve quality. For example, as part of an ongoing effort to achieve improved patient outcomes, we announced the ESRD Disease Management Demonstration in the Federal Register on June 4, 2003. The goal of this demonstration is to achieve improved patient outcomes through disease management services and quality incentives. This demonstration does not directly involve renal physicians, but we are considering the use of quality incentives in potential future payment systems for them as well. Renal physicians play a central role in leading the interdisciplinary team charged with managing an ESRD patient?s care.<
>Thus, we are seeking comment on how to further revise our payment methodology to improve quality of care and outcomes. We are also interested in information that could help us design future demonstrations that would incorporate both dimensions of care (quality and utilization) and help ensure that payment is based on appropriate patient specific care that has been shown to lead to improved outcomes for this complex patient population.<
>
****************************************************************
leadsag
Joined: 31 Oct 2002
Posts: 263
Posted: Tue Aug 12, 2003 1:10 pm Post subject: progress
--------------------------------------------------------------------------------
Sounds like some progress was made.<
><
>I wonder if the Dialysis RN or a PA count as a 'visit' for reimbursement purposes?
****************************************************************
DJ
Joined: 31 Jan 2003
Posts: 19
Posted: Tue Aug 12, 2003 8:18 pm Post subject: CMS meeting
--------------------------------------------------------------------------------
Go DEO!
****************************************************************
patientwife
Joined: 18 Jul 2003
Posts: 47
Posted: Tue Aug 12, 2003 9:24 pm Post subject: CMS Meeting
--------------------------------------------------------------------------------
I, too, deem it a privilege to have participated with other members of DEO who met with CMS. (I am Pat Tate-Harris from Baton Rouge, Louisiana). As one who had previously participated in such meetings many, many times before re health-related matters, I was impressed that CMS staff "heard" us. "Hearing us" does not mean "carte blanche" agreement with our, DEO's, positions, but that they will be taken into consideration as efforts to improve quality of services for dialysis patients continue.<
><
>My specific contribution related to the critical need for patients to be involved in development of their treatment care plans. I see this as a need from the onset of dialysis treatment as it provides opportunity for much. First, it establishes that the patient is an equal partner (with physician, nurse, nutritionist and social worker) in the program supposedly designed to address medical issues and improve quality of life; it provides an opportunity for patients to be educated about needs and behaviors only the patient can accomplish but that will translate into a better life for the patient; and, it establishes a personal relationship between the patient and care team. Without these elements, there is no true treatment plan. Rather, the patient is repeatedly subjected to that about which so many of us complain -- a "jiffy lube", "assembly line" process of dialysis procedures.<
><
>Though our meeting with CMS may be considered successful, we must not hesitate in our vigilant efforts to effect changes and to
ing our issues to the forefront. CMS is "government", and sadly, it often takes "government" too long to make needed changes --too long for the sake of lives. We must continue to take the dialysis units and industry to task when we know that they are harming dialysis patients.<
><
>Things are changing! Let's continue to be a part of it!<
> <
><
><
><
><
><
>
****************************************************************
patient
Joined: 29 Oct 2002
Posts: 137
Posted: Wed Aug 13, 2003 6:24 am Post subject: what was gained?
--------------------------------------------------------------------------------
Can someone say what the changes above mean? Looks like doctor gets paid less if he short changes patients on visits. Anything else? Was the above decided before the meeting or after?
****************************************************************
leadsag
Joined: 31 Oct 2002
Posts: 263
Posted: Wed Aug 13, 2003 1:31 pm Post subject: Meeting
--------------------------------------------------------------------------------
Apparantly this was in the works BEFORE the meeting since something of this magnitude could not have just been thrown together overnight.
****************************************************************
Disgusted
Joined: 26 Jan 2003
Posts: 45
Posted: Thu Aug 14, 2003 2:18 am Post subject: meeting
--------------------------------------------------------------------------------
It is essential that DEO participate with a council of clinic patients or family to continue to update CMS and
ing them up to speed with what is happening in the units. The nephs and the providers are holding hands with the networks and not telling the complete story on what is going on, this is why a impartial group that is exposed to this needs to be involved. When money is involved (such as with dr's, providers, and networks) stories begin to change.
****************************************************************
ridgerunner
Joined: 11 Jan 2003
Posts: 101
Posted: Thu Aug 14, 2003 3:07 am Post subject: meeting
--------------------------------------------------------------------------------
in reading what the govt plans on doing is do much double talk. they have not adressed the the basic issues reuse adaquate treatment, choices of treatment. the only thing i can see that they are doing is addressing thing that very seldom happen. its like getting ins. that pays if you are hit by a moon rock, in my opinion they have shafted the doctors.
****************************************************************
Disgusted
Joined: 26 Jan 2003
Posts: 45
Posted: Thu Aug 14, 2003 3:57 am Post subject: neph visit
--------------------------------------------------------------------------------
My doctor has seen me once in a year sitting in his dialysis chair. The rest of the time I have to drive many miles sick or not to see him. For the amount of money that he is paid per month I beleive he can get in his car and drive to his clinic and see me
once a month sitting in his chair to make sure that I am in one piece still, especially since state laws are in place that he visit his patients once a month anyway but somehow he does not. Under the old way I was getting the shaft.
****************************************************************
plugger
Joined: 11 Jan 2003
Posts: 236
Posted: Thu Aug 14, 2003 5:16 am Post subject: Thanks to all the people who went to the CMS meeting!
--------------------------------------------------------------------------------
This meeting sounds like a good foot in the door. At least now they are sitting down and listening to people who have their health at stake with this. And not just lobbyists and others who have more of an interest in keeping the money train chugging.
****************************************************************
John
Joined: 18 Nov 2002
Posts: 8
Posted: Thu Aug 14, 2003 6:56 am Post subject: doctor visits
--------------------------------------------------------------------------------
My neph rounds once a week. Now you would think that's good right? But he gives me terrible answers to questions and speaks condescendingly to me. He acts like I'm a quack if I display any knowledge of my tx. He's rude and runs off on me in less than a minute. So, just because a doctor visits you more often doesn't guarantee it will benefit you. If I had one that came less often, but who was really knowledgeable and treated me like a team player, I'd get more out of it.
****************************************************************
