Dear (Senator):
For years patients with End Stage Renal Disease (ESRD) receiving dialysis in the United States have had the highest mortality rate in the world. Patients on hemodialysis require a mechanism to get blood from their bodies, into the dialysis machine and back.
To accomplish this surgically created conduits called grafts, catheters and fistulas are
created. In the US a much higher proportion of patients have grafts and catheters
placed rather than fistulas. Fistulas are recognized to be superior and to be associated
with a sharply lower mortality rate. To this end all major organizations dealing with
ESRD have funded and promoted programs to urge and facilitate the augmentation of
fistula prevalence in the US. These supporting organizations include the American Society of Nephrology, the Renal Physicians Association, the National Kidney Foundation,
the Fistula First Initiative, the American Society of Diagnostic and Interventional Nephrology.
One of the most important accomplishments of these efforts has been the emergence of
specialty centers or Access Centers, which deal exclusively with diagnosis and management of problems occurring in dialysis access. The majority of these Access Centers
are operated by nephrologists, the specialty physicians exclusively charged with the
management of dialysis patients. The centers are operated largely as extensions of the
physicians office practices and capitalized by them. Prior to the establishment of this
effort and these centers, the national prevalence of fistulas was 20 %. With the acceleration of this effort has been a national rise in the prevalence of fistulas of 10 % with
many of the largest practices in the US achieving a rate of 60 %.
As a partner in this effort, CMS has recently facilitated reimbursement for these centers
resulting in nephrologists around the country to own or partner as owners of Access
Centers. Thus in the foreseeable future the majority of ESRD patients in the country will
have access to these centers. Unfortunately, the House version of the Children’s Health
and Medicare Protection Act of 2007 (H.R. 3162) has provisions in it which will force the
closure of many of these centers and prohibit all but the largest practices in the country
from establishing and operating them. Severe limitation of access to these centers for
ESRD patients will undoubtedly result. The effort to promote fistula creation will be severely impacted. This legislation includes language promoting a "fix" to the sustainable
growth rate (SGR) method of calculating physician reimbursement that would cause a
major loss of access for Medicare beneficiaries to many types of minimally invasive
therapies which are used in the maintenance of dialysis vascular access. We believe
that the legislative repair being proposed would stymie the development of targeted,
less-invasive and more cost-effective therapies by creating financial disincentives for
such treatments. This current piece of legislation does not recognize the difference between older, more invasive, less targeted therapies (whether major surgeries or minor
procedures) and the newer, less invasive, highly targeted therapies that have promoted
the increase in fistula prevalence.
This legislation divides physician services into different categories - and thus physicians; enacting 6 different conversion factors based on these categories or "buckets".
The proposed buckets and projected changes in reimbursement (not including an adjustment for inflation) are as follows:
1:Primary and preventive 49%
2:Other E/M -5%
3:Surgery 8% includes only 10-day and 90-day "major" surgery
4:Other procedures -21% includes all 0-day global, minimally invasive surgeries
5:Anesthesia 37%
6:Imaging -21%
*with adjustment for inflation, both "other procedures" and "imaging" are expected to
result in a 40% decrease in reimbursement for these buckets.
The long-term SGR "fix" being proposed is not sufficiently well-constructed, and its true
ramifications are incompletely evaluated. Our great concern is that the Congress is "incentivizing" open surgery (without regard to its effectiveness, total costs and patient
benefits) over minimally invasive alternative treatments (again without consideration of
the differences among the myriad services included in this category).
A subcommittee has attached this "added" piece of legislation, which we do not believe
is capable of standing by itself, to a matter of critical importance for the children of our
nation. While it is difficult to argue against improving the health of our children, this legislation would severely and negatively impact the access to health care for all patients
with ESRD in the United States. This section has been included in the version of this
legislation in the House of Representatives but not the Senate. Should it pass we urge
you to work to eliminate it from the conference bill.