First Word

By Mark E. Neumann


Welcome to First Word. Each month, I'll be discussing important topics inside and outside the renal community, and asking for your views on how we might change or improve the way we do things in renal care. The column title, "First Word," means that I won't have the last word---that will be yours. Let's keep the dialogue interesting. You can always reach me at mneumann@nephronline.com, or toll-free at 866.944.9619.

Since we are starting a new year, it seems fitting to talk about what lies ahead. And there is plenty. New regulations like the Conditions for Coverage will change how dialysis facilities need to comply with Medicare rules for providing dialysis treatments. New payment models under development, like bundling, will be controversial. Although portions of the current dialysis payment process is bundled, like the composite rate (the definition of composite is "made up of disparate or separate parts or elements"), Medicare reform that took place this past summer will, like the new Conditions, bring the ESRD program into the 21st cent-ury. But finding a middle ground that allows both small and large providers to make a fair profit and provide good care-and allow payers like Medicare to feel they have costs under control-will surely result in a tug-of-war with little middle ground.

The Medicare Fee Schedule for 2009 had some holiday gifts for nephrologists, although its not clear what the long-term plans are to keep the gifts on the table (see Rob Blaser's Renal Policy column on p. 27 of this  month's issue). Congress needs to put together a plan to permanently fix the fee schedule for physicians so we don't have an 11th-hour scramble. Being in an occupation where every year you are threatened with a pay cut, regardless of your best efforts to take care of patients, is not an encouraging environment.

Would a pay-for-performance component make a difference? Can we rely on practice guidelines to guide both reimbursement and practice? Some are doubtful. Such guidelines are too often prepared based on opinion and may be outdated soon after implementation. On the other hand, it seems fair for a payer to expect caregivers to adhere to certain standards and outcomes be reached before paying the bill.

Finally, the introduction of CROWNWeb looms before us. The Centers for Medicare & Medicaid Services' plan to move from a 5% sampling of dialysis patient data to collecting 100% of data from more than 350,000 patients each year is indeed ambitious. Providers need to feel comfortable that the collection system being put in place is trustworthy and reliable-and carefully tested-before the data is shared with the public. CMS has promised to make sure that happens. The renal community needs to hold the agency to its word.
 

Mr. Neumann has been the executive editor of Nephrology News & Issues since 1989.