Cognitive Dissonance at the Subcommittee on Health hearing Tuesday
by billp830, Thu Jun 28, 2007 at 12:12:04 PM EDT
The House Committee on Ways and Means Subcommittee on Health on Tuesday 6/26 held a Hearing on Ensuring Kidney Patients Receive Safe and Appropriate Anemia Management Care. Congressman Stark chaired the hearing to review Medicare's policies regarding anemia management. In general there is concern in Congress that Medicare (CMS) reimbursement policies may lead to clinically dangerous over use of medications used to treat dialysis patient anemia and there is concern that CMS is paying too much to manage dialysis patient anemia.
My previous diaries here and here present my view of the "bundling" solution to the perceived problem of anemia medication over use. My diaries here and here attempt to explain the current situation with regard to Epogen, the primary medication administered by dialysis providers to treat anemia in people on dialysis. I have an opinion piece posted here that reviews the unique way that dialysis is paid for in the United States; the opinion piece grew out of this diary which gives some history of the US dialysis entitlement.
The GAO and MedPAC are in favor of bundling but their evaluation criteria is financial, not clinical. More troubling was the testimony by the American Association of Kidney Patients (aakp) they present themselves as "the voice of all kidney patients" (count at least one person out. I'll speak for myself) testifying that they are dedicated to serving "the needs, interests, and welfare of all kidney patients and their families". That would be good, but the testimony that I heard could only be summarized as a case of cognitive dissonance.
The temptation is to provide the aakp's written testimony line by line, but instead I'll just post the bit directly talking about bundling (their emphasis):
Because every medical case is unique, AAKP strongly adheres to the principle that a physician and patient must be permitted to decide a care plan best suited for that patient. Averages and other statistics are fine for certain purposes, but let's remember that medicine is fundamentally about the treatment of a unique individual.
In this light, we worry about any policy that clouds the doctor/patient decision-making relationship for treatment options. Separate Medicare reimbursement for ESAs potentially distracts from the doctor and patient deciding which course to pursue. That is why we support bundling Medicare reimbursement for ESAs into the overall Medicare composite reimbursement rate for ESRD. We believe that bundling the payment would not only result in cost savings, but also would result in more appropriate dosing of ESAs and draw more attention to the necessarily comprehensive nature of kidney care. It is important, however, to ensure that any bundling structure include risk-adjustment so as not to inadvertently create a disincentive for providers to cover the sickest patients.
Does this make sense?
"In this light, we worry about any policy that clouds the doctor/patient decision-making relationship for treatment options. Separate Medicare reimbursement for ESAs potentially distracts from the doctor and patient deciding which course to pursue. That is why we support bundling Medicare reimbursement or ESAs into the overall Medicare composite reimbursement rate for ESRD."
What are they trying to say? How could the aakp be in favor of a wholesale change in the US dialysis reimbursement system sight unseen? What I am reading is that the aakp is in favor of fewer resources going into dialysis care. Fewer resources because the current reimbursement structure "distracts from the doctor and patient deciding which course to pursue."
The aakp's position seems to be that the 10% margin that large dialysis organizations (i.e. Davita and FMC) make on administering EPO to Medicare primary patients "clouds" the doc's decision making process. The aakp reports to be worried that the LDO's 10% Epogen margin "potentially distracts from the doctor and patient deciding which course to pursue."
I don't think that is true but let's assume that it is, if you believed that then the last thing you'd want is bundling. Bundling turns medications into pure expenses. Surely, if a 10% carrot boggles the doc's decision making ability then a 100% stick would be far, far worse. The whole premise of bundling is that a tiny incentive is motivating bad decisions, therefor we should create a much larger incentive to fix the problem. That's cognitive dissonance right?
A encouraging note was struck by Congressman Stark who said (or words to this effect, we're still waiting for the transcript): "We can create incentives that will lead either to over dosing or to under dosing." This may be true. If it is then why not do both? CMS could error on the side of overdosing for those patients willing to have subq Epogen administration and error on the side of under dosing for those patients who choose to have their Epogen administered intravenously. One target and titrating protocol for subq and a more conservative target and protocol for intravenous administration.
The key point I would think patients and our supporters (including the aakp) should make is that any savings from spending less on dialysis medications must stay in the federal dialysis program. I think that the position of dialysis advocates should be that if the question is "How can we decrease the ESRD burden - on both the patient and society (the taxpayer)?", then the answer is dialysis. Dialysis is the solution. With longer and more frequent treatments comes savings on medications, savings on hospitalizations and savings on the human misery that comes with chronic under dialysis. The inexplicable position of the aakp is that "Our nation has the unique opportunity to provide better outcomes for kidney patients - and this can lead to substantial cost savings because better outcomes translate into less reliance on the drugs, dialysis, and hospitalization currently covered by Medicare." What strategy of treating dialysis patients could possibly result in less reliance on the drugs & dialysis?
The aakp seems to be saying that they think from substantial cost savings (i.e. CMS spending less money on dialysis patients - fewer resources supporting dialysis patients) will flow better outcomes. While I agree that taking money out of the dialysis program will result in less dialysis it is manifest that less dialysis will lead to worse outcomes. That's cognitive dissonance right?
If the goal is to save money through using less Epogen, and if administering Epogen directly into the muscle (subq) will require less Epogen then CMS should go to subq directly rather than indirectly via bundling. Studies consistently show that equivalent hematocrits can be achieved with 20% less medication if it is administered subq. Of course patients don't like it (despite what the aakp says, more cognitive dissonance) because it requires an additional needle stick. But if the government needs everyone to make a bit of sacrifice (though I don't recall hearing that message from the administration) then I think it is reasonable to ask dialysis patients accept the discomfort of an avoidable shot.
Again, what I think is critical is keeping the savings in the ESRD program. A 20% ESA reduction from subq administration would create a $360 million a year pay go credit - that would pay for HR1193/S635 and last year's HR5321 without extending the private payer period. A good idea. This would be a fair use of savings that are built on patients having to accept a third needle stick each treatment.
It seems manifest that bundling would turn medications into costs to be controlled - along with 4x4s, band-aids and staff time - and corporations know nothing if not how to control costs. I am sure any renal professional could come up with policies that would lower costs (i.e. use less medication) in a bundled environment where medications are a pure expense. I am not sure that those cost control measures would advance patient care. And, I am not sure that bundling would in fact save money. It depends on the details of the bundling scheme and what is done about outliers. We should save money on ESAs, while maintaining patient choice and use those savings to pay for HR1193/S635 without extending the private pay period and we should fund Congressman McDermott's HR5321 from last year.
Bundling, as it is normally understood, would either result in increased large dialysis organization (LDO, basically Davita and FMC who provide 70% of all US dialysis treatments) profits (the testimony Leslie V. Norwalk, Acting Administrator, Centers for Medicare and Medicaid Services included a statement that the cost of a unit of EPO for the LDOs is in the $8.50 range while the cost for the small or independent (I cannot remember which term was used) would be in the $8.95/unit range; reimbursement is $9.03) or it would result in financial hardship for the non-LDOs. It is hard to imagine a bundled rate that would impact all providers similarly. Either it would be a windfall to the LDOs or it would financially squeeze small providers.
I did not hear a compelling case for bundling. I did hear that some people seemed resigned to bundling. I can not imagine how someone could be for bundling without knowing the details. Without some sort of novel mechanism (that has yet to be described) a bundled rate will represent a missed opportunity, it will be another case of progress in dialysis care being defined as increased economic efficiency rather than improved outcomes. We should work to improve clinical outcomes. Outcomes that have a real significant impact such as lower mortality rates and/or lower hospitalization rates.
I hope Congressman Stark will slow the rush to bundling. I hope the Committee will proceed with caution, conversation and commitment to patient well being as the driving force behind any legislative change. Bundling is indeed a compelling economic model, but one with significant potential pitfalls. Congressman Stark did ask Ms. Norwalk if CMS could purchase Epogen directly and supply all dialysis providers with EPO at a low negotiated price using CMS's buying power. Since this medication is administered under Medicare Part B, not Part D, it sounded like it was a possibility. This strategy should be investigated.