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AAP 2010 ESRD PPS NPRM Comment pdf-final

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   December 16, 2009 141 Northwest Point Blvd  Elk Grove Village, IL 60007-1098 Phone: 847/434-4000 Ms Charlene Frizzera Fax: 847/434-8000 Acting Administrator E-mail: kidsdocs@aap.org www.aap.org Centers for Medicare and Medicaid Services Department of Health and Human Services Attention: CMS‐1418‐P Mail Stop C4‐26‐05 Executive Committee 7500 Security Boulevard President Baltimore, MD 21244‐1850 Judith S. Palfrey, MD, FAAP  President-Elect Re: Medicare Program; End‐Stage Renal Disease Prospective Payment System; Proposed Rule; O. Marion Burton, MD, FAAP CMS‐1418‐P Immediate Past President  David T. Tayloe, Jr, MD, FAAP Dear Ms Frizzera: Executive Director/CEO  Errol R. Alden, MD, FAAP The American Academy of Pediatrics (AAP) appreciates the opportunity to provide comments on the Notice of Proposed Rulemaking entitled “Medicare Program; End‐Stage Renal Disease Board of Directors Prospective Payment System; Proposed Rule.” The Academy offers these comments on the District I proposed rule to ensure that new End‐Stage Renal Disease (ESRD) Prospective Payment System Edward N. Bailey, MD, FAAP policies appropriately accommodate the unique aspects of health care services delivered to Salem, MA children. District II  Henry A. Schaeffer, MD, FAAP Brooklyn, NY • Reducing the pediatric (<18 years old) case mix adjustor (CMA) for facility District III reimbursement from 1.62 to 1.199 or below will lead to an unintended consequence of Sandra ...
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December16,2009141 Northwest Point Blvd Elk Grove Village, IL 600071098Phone: 847/4344000 MsCharleneFrizzeraFax: 847/4348000 Email: kidsdocs@aap.orgActingAdministratorwww.aap.org CentersforMedicareandMedicaidServicesDepartmentofHealthandHumanServicesAttention:CMS1418PMailStopC42605Executive Committee 7500SecurityBoulevardPresident Baltimore,MD212441850Judith S. Palfrey, MD, FAAP PresidentElect Re:MedicareProgram;EndStageRenalDiseaseProspectivePaymentSystem;ProposedRule;O. Marion Burton, MD, FAAP CMS1418PImmediate Past President David T. Tayloe, Jr, MD, FAAP DearMsFrizzera:Executive Director/CEO Errol R. Alden, MD, FAAP TheAmericanAcademyofPediatrics(AAP)appreciatestheopportunitytoprovidecommentsontheNoticeofProposedRulemakingentitled“MedicareProgram;EndStageRenalDiseaseBoard of Directors ProspectivePaymentSystem;ProposedRule.”TheAcademyoffersthesecommentsontheDistrict I proposedruletoensurethatnewEndStageRenalDisease(ESRD)ProspectivePaymentSystemEdward N. Bailey, MD, FAAP policiesappropriatelyaccommodatetheuniqueaspectsofhealthcareservicesdeliveredtoSalem, MA children.District II Henry A. Schaeffer, MD, FAAP Brooklyn, NY Reducingthepediatric(<18yearsold)casemixadjustor(CMA)forfacilityreimbursementfrom1.62to1.199orbelowwillleadtoanunintendedconsequenceofDistrict III Sandra Gibson Hassink, MD, FAAP pediatricESRDpatientslosingaccesstonecessarytreatments.Wilmington, DE TheuniqueneedsofchildrenandadolescentshavebeenunderestimatedbyCMS’o District IV Francis E. Rushton, Jr, MD, FAAPESRDProposedPaymentSystem(PPS)regressionmethodology.CMSpreviouslyBeaufort, SC hasrecognizedtheincreasedcostofdialyzingchildren,bothinthegrantingofDistrict VpediatricdialysisfacilityexceptionstoreimbursementandintheprovisionoftheMarilyn J. Bull MD, FAAP temporarypediatricCMAof1.62in2005.Pediatricdialysisunits(>50%patientIndianapolis, IN <18yearsold)withexception,mostofwhichareassociatedwithchildren’sDistrict VI hospitals,weregrantedhigherfacilityratesbasedontheiractualcostsintheirMichael V. Severson, MD, FAAP Medicarecostreports,includinghigherpersonnelstaffing,highercostsofBrainerd, MN pediatricspecificdialysisdisposableequipment,andhighercostsofsupportforDistrict VII homecareofchildrenandtheircaregiverfamilies.DatafrompediatricunitsKenneth E. Matthews, MD, FAAP College Station, TX providethebestassessmentofcostsforpediatricspecificservicesUseoftheproposedpediatricCMAandeliminationofthepediatricfacilityo District VIII Mary P. Brown, MD, FAAP exceptionswillreducethecostadjustmentneededbymanypediatricfacilitiestoBend, OR remainoperational.Withoutpediatricdialysisunits,ourchildrenandadolescentsDistrict IX Myles B. Abbott, MD, FAAPwithESRDwillnothaveaccesstothespecializeddialysiscarethattheyneedandBerkeley, CA whichhasbeenthedrivingforceforimprovementinoutcomesandadvancesinDistrict Xdialysistreatmentforthisuniquegroupofpatients.John S. Curran, MD, FAAP Furthermore,theproposedlowerpediatricCMAadjustorsof1.199orlesswillbeo Tampa, FL adisincentiveforadultunitstocontinuetoprovidedialysisforthefewchildrenwhoaregeographicallyunabletobecaredforatapediatriccenter.
Pediatricpatientsaccountforjustlessthan0.6%oftheprevalentdialysispopulationandonlyabout0.2%ofdialysisMedicarebeneficiaries.Theuniqueservicesprovidedinpediatricdialysisunitsarevitalforthecareofthissmall,vulnerablepopulation.AlthoughareductioninreimbursementasproposedbyCMSwouldhaveao negligibleeffectontheMedicareprogram,thesechangescouldpotentiallydevastatetheviabilityoffacilitiesspecializinginthetreatmentofthisvulnerablepopulation.Childrenandadolescentsundertheageof18arenotyetfullydevelopedandareo dependentonadultstoprovideagespecificsupervisionandcareduringdialysistreatmentsandforhomecare.ThesmallestandyoungestchildrenrequireonetoonenurseorhomecaregivercareduringHDorPDtreatmentstoensuresafetyandefficacy.hildrenreceivingdialysisrangeinsizefrom3kgnewbornsto90kgteenagers,sooC requireawidevarietyofspecializeddialyzers,bloodlines,andothersupplies,mostofwhichareexpensiveandonlymadebyoneoratmosttwovendors.llarypediatricpersonnelarebothrequiredandessentialtopediatricdialysis,oAnci notonlyindealingwiththesmallestchildren,butalsoindealingwithadolescents,whohavesignificantproblemswithdialysis,includingbehavioraladjustment,adherencetodietaryrestrictionsandmedications,andmaintainingschoolperformance.TheproposedESRDPPSCMAforpediatricsisbasedonastatisticalregressionmodelthatisflawedforpediatricsduetothesmallnumberofpediatricpatientsusedinthedataanalysisandtomissingandincompletecostdataforpediatricdialysisunits.ThecurrentCMSmodeldoesnotfairlyrepresenttheactualdatafromcosto reportsofpediatricdialysisunitsandisdistortedbythepediatricpatientsdialyzedinadultunits,whosefacilitycostsrepresenttheadultcostsofthoseunitsandnotpediatricspecificservices.Inaddition,methodologyforestimatingseparatelybillableservicesforpediatricpatientswasbasedonasmallsamplewithlimitedstatisticalpowerandislikelymissingsignificantdatafromunderreportingofseparatepediatricclaims.Theproposedmodifierdoesnottakeintoaccountpediatricspecificcosts,coo morbiditiesandotherspecialneedsofthepediatricESRDpopulation,soisseverelyundervalued.PediatricpatientsalmostneverhavethecomorbiditiesdesignatedintheproposedESRDPPS,butdohavepediatricspecificcomorbidities,includingrenalosteodystrophy,growthretardation,developmentaldelay,deafness,seizuredisorder,raregeneticdiseasesandotherorgansystemdisorders.Dialysisnurses,dietitians,socialworkers,ChildLifeSpecialists,tutors,ando psychologistswithspecializedpediatrictrainingandexpertisearerequiredandessentialforthecareofchildrenandadolescents.CMSshoulduseasinglecategoryCMAforpediatricpatients.Usingmultiplepaymentcategoriestoadjustforage,modalityandadultcomorbiditiesunnecessarilycomplicatestheproposedESRDPPSforpediatricdialysispatients(Table33,p260).oTheproposedpediatricratesarelowestfortheyoungestpatients(<13yearsold),whichiscompletelycontrarytoanddoesnotaccountforthetechnicalcomplexityandhighcostofstaffingandspecializedsuppliesinvolvedindialyzingthisgroupofchildren.oAssigningasinglepediatricCMAregardlessofmodalitywillallowpediatricnephrologistsandfamiliestochoosetherightdialysismodalityforeachchild.Currently,about50%ofpediatricpatientsaretreatedwithhomePD.ThetechnicalaspectsofprovidinghomePDsupportforparentcaregiversandforadolescentselfcarepatientsleadtohighercostsandappearsundervaluedbythe
proposedmodalitybasedformulas.oTheacceptablecomorbiditiesstatedintheESRDPPS(diabetes,alcohol/drugdependence,etc)areforadultsanddonotoftenapplytochildren.CommonpediatricESRDcomorbiditiesarenotaddressed,includingpulmonaryhypoplasia,developmentaldelay,failuretothrive,seizuredisorder,deafness,congenitalheartdisease,othersolidorgantransplantation,andrenalosteodystrophyofgrowingbones.MostpediatricdialysispatientswouldnotbeclassifiedashavingcomorbiditiesusingtheproposedESRDPPSlist.TheAmericanAcademyofPediatricsasksthatCMSprovideamoreappropriatesinglecategoryCMAforpediatricdialysispatients.ThepediatricCMAshouldbebasedonaseparatepediatricspecificanalysisofactualcosts,includingdataforthemajorityofpatientswhoaredialyzedinpediatricdialysisunitsandincludingpediatricspecificcomorbidities,andnotontheproposedregressionmethodology,whichhasflawswhenappliedtosuchasmallpopulationwithincompletedata.WerequestthatCMSworkwithleadersofthepediatricdialysiscommunitytoo considerananalysisthatwouldincludeallaspectsofthecostforpediatricdialysispatientstodetermineanappropriatepediatricCMA.WeanticipatethatsuchananalysiswillresultinamoreaccuratepediatricCMAthancurrentlyproposed,andbemoreinlinewithreimbursingactualcoststothecountry'svitalpediatricESRDfacilities.CMSmaywanttoconsiderpostponingtheapplicationofthebundledpaymento systemtothepediatricpopulationuntilmoreaccuratedatacanbecollectedandtheactualcostsofcaringforsuchavulnerablepopulationcanbeanalyzedinmoredetailbyCMS.TheAcademyappreciatestheopportunitytoprovidecommentsontheproposedruleandlooksforwardtoworkingwithCMStoensurethattheESRDProspectivePaymentSystemaccommodatestheuniqueaspectsofhealthcareservicesdeliveredtochildren.Sincerel ,
JudithS.Palfrey,MD,FAAPPresidentJSP/sk
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