AAP 2010 ESRD PPS NPRM Comment pdf-final

Mary Williamson

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   December 16, 2009 141 Northwest Point Blvd  Elk Grove Village, IL 60007-1098 Phone: [phone] Ms Charlene Frizzera Fax: [phone] Acting Administrator E-mail: [e-mail] 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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• Publié par: Choim
• Nombre de lectures: 98
• Langue: Español

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December16,2009 141 Northwest Point Blvd Elk Grove Village, IL 600071098 Phone: 847/4344000 MsCharleneFrizzera Fax: 847/4348000 Email: [e-mail] ActingAdministrator www.aap.org CentersforMedicareandMedicaidServices DepartmentofHealthandHumanServices Attention:CMS‐1418‐P MailStopC4‐26‐05 Executive Committee 7500SecurityBoulevard President Baltimore,MD21244‐1850 Judith S. Palfrey, MD, FAAP PresidentElect Re:MedicareProgram;End‐StageRenalDiseaseProspectivePaymentSystem;ProposedRule; O. Marion Burton, MD, FAAP CMS‐1418‐P Immediate Past President David T. Tayloe, Jr, MD, FAAP DearMsFrizzera: Executive Director/CEO Errol R. Alden, MD, FAAP TheAmericanAcademyofPediatrics(AAP)appreciatestheopportunitytoprovidecommentson theNoticeofProposedRulemakingentitled“MedicareProgram;End‐StageRenalDisease Board of Directors ProspectivePaymentSystem;ProposedRule.”TheAcademyoffersthesecommentsonthe District I proposedruletoensurethatnewEnd‐StageRenalDisease(ESRD)ProspectivePaymentSystem Edward N. Bailey, MD, FAAP policiesappropriatelyaccommodatetheuniqueaspectsofhealthcareservicesdeliveredto Salem, MA children. District II Henry A. Schaeffer, MD, FAAP Brooklyn, NY •Reducingthepediatric(<18yearsold)casemixadjustor(CMA)forfacility reimbursementfrom1.62to1.199orbelowwillleadtoanunintendedconsequenceof District III Sandra Gibson Hassink, MD, FAAP pediatricESRDpatientslosingaccesstonecessarytreatments. Wilmington, DE TheuniqueneedsofchildrenandadolescentshavebeenunderestimatedbyCMS’o District IV Francis E. Rushton, Jr, MD, FAAP ESRDProposedPaymentSystem(PPS)regressionmethodology.CMSpreviously Beaufort, SC hasrecognizedtheincreasedcostofdialyzingchildren,bothinthegrantingof District V pediatricdialysisfacilityexceptionstoreimbursementandintheprovisionofthe Marilyn J. Bull MD, FAAP temporarypediatricCMAof1.62in2005.Pediatricdialysisunits(>50%patient Indianapolis, IN <18yearsold)withexception,mostofwhichareassociatedwithchildren’s District VI hospitals,weregrantedhigherfacilityratesbasedontheiractualcostsintheir Michael V. Severson, MD, FAAP Medicarecostreports,includinghigherpersonnelstaffing,highercostsof Brainerd, MN pediatric‐specificdialysisdisposableequipment,andhighercostsofsupportfor District VII homecareofchildrenandtheircaregiverfamilies.Datafrompediatricunits Kenneth E. Matthews, MD, FAAP College Station, TX providethebestassessmentofcostsforpediatric‐specificservices UseoftheproposedpediatricCMAandeliminationofthepediatricfacilityo District VIII Mary P. Brown, MD, FAAP exceptionswillreducethecostadjustmentneededbymanypediatricfacilitiesto Bend, OR remainoperational.Withoutpediatricdialysisunits,ourchildrenandadolescents District IX Myles B. Abbott, MD, FAAP withESRDwillnothaveaccesstothespecializeddialysiscarethattheyneedand Berkeley, CA whichhasbeenthedrivingforceforimprovementinoutcomesandadvancesin District X dialysistreatmentforthisuniquegroupofpatients. John S. Curran, MD, FAAP Furthermore,theproposedlowerpediatricCMAadjustorsof1.199orlesswillbeo Tampa, FL adisincentiveforadultunitstocontinuetoprovidedialysisforthefewchildren whoaregeographicallyunabletobecaredforatapediatriccenter.

•Pediatricpatientsaccountforjustlessthan0.6%oftheprevalentdialysispopulation andonlyabout0.2%ofdialysisMedicarebeneficiaries.Theuniqueservicesprovidedin pediatricdialysisunitsarevitalforthecareofthissmall,vulnerablepopulation. AlthoughareductioninreimbursementasproposedbyCMSwouldhaveao negligibleeffectontheMedicareprogram,thesechangescouldpotentially devastatetheviabilityoffacilitiesspecializinginthetreatmentofthisvulnerable population. Childrenandadolescentsundertheageof18arenotyetfullydevelopedandareo dependentonadultstoprovideage‐specificsupervisionandcareduringdialysis treatmentsandforhomecare.Thesmallestandyoungestchildrenrequireone‐ to‐onenurseorhomecaregivercareduringHDorPDtreatmentstoensuresafety andefficacy. hildrenreceivingdialysisrangeinsizefrom3kgnewbornsto90kgteenagers,sooC requireawidevarietyofspecializeddialyzers,bloodlines,andothersupplies, mostofwhichareexpensiveandonlymadebyoneoratmosttwovendors. llarypediatricpersonnelarebothrequiredandessentialtopediatricdialysis,oAnci notonlyindealingwiththesmallestchildren,butalsoindealingwith adolescents,whohavesignificantproblemswithdialysis,includingbehavioral adjustment,adherencetodietaryrestrictionsandmedications,andmaintaining schoolperformance. •TheproposedESRDPPSCMAforpediatricsisbasedonastatisticalregressionmodel thatisflawedforpediatricsduetothesmallnumberofpediatricpatientsusedinthe dataanalysisandtomissingandincompletecostdataforpediatricdialysisunits. ThecurrentCMSmodeldoesnotfairlyrepresenttheactualdatafromcosto reportsofpediatricdialysisunitsandisdistortedbythepediatricpatients dialyzedinadultunits,whosefacilitycostsrepresenttheadultcostsofthose unitsandnotpediatricspecificservices.Inaddition,methodologyforestimating separatelybillableservicesforpediatricpatientswasbasedonasmallsample withlimitedstatisticalpowerandislikelymissingsignificantdatafromunder‐ reportingofseparatepediatricclaims. Theproposedmodifierdoesnottakeintoaccountpediatricspecificcosts,co‐ o morbiditiesandotherspecialneedsofthepediatricESRDpopulation,sois severelyundervalued.Pediatricpatientsalmostneverhavetheco‐morbidities designatedintheproposedESRDPPS,butdohavepediatric‐specificco‐ morbidities,includingrenalosteodystrophy,growthretardation,developmental delay,deafness,seizuredisorder,raregeneticdiseasesandotherorgansystem disorders. Dialysisnurses,dietitians,socialworkers,ChildLifeSpecialists,tutors,ando psychologistswithspecializedpediatrictrainingandexpertisearerequiredand essentialforthecareofchildrenandadolescents. •CMSshoulduseasinglecategoryCMAforpediatricpatients.Usingmultiplepayment categoriestoadjustforage,modalityandadultco‐morbiditiesunnecessarily complicatestheproposedESRDPPSforpediatricdialysispatients(Table33,p260). o Theproposedpediatricratesarelowestfortheyoungestpatients(<13yearsold), whichiscompletelycontrarytoanddoesnotaccountforthetechnicalcomplexity andhighcostofstaffingandspecializedsuppliesinvolvedindialyzingthisgroup ofchildren. o AssigningasinglepediatricCMAregardlessofmodalitywillallowpediatric nephrologistsandfamiliestochoosetherightdialysismodalityforeachchild. Currently,about50%ofpediatricpatientsaretreatedwithhomePD.The technicalaspectsofprovidinghomePDsupportforparentcaregiversandfor adolescentself‐carepatientsleadtohighercostsandappearsundervaluedbythe

proposedmodality‐basedformulas. o Theacceptableco‐morbiditiesstatedintheESRDPPS(diabetes,alcohol/drug dependence,etc)areforadultsanddonotoftenapplytochildren.Common pediatricESRDco‐morbiditiesarenotaddressed,includingpulmonaryhypoplasia, developmentaldelay,failuretothrive,seizuredisorder,deafness,congenital heartdisease,othersolidorgantransplantation,andrenalosteodystrophyof growingbones.Mostpediatricdialysispatientswouldnotbeclassifiedashaving co‐morbiditiesusingtheproposedESRDPPSlist . •TheAmericanAcademyofPediatricsasksthatCMSprovideamoreappropriatesingle categoryCMAforpediatricdialysispatients.ThepediatricCMAshouldbebasedona separatepediatric‐specificanalysisofactualcosts,includingdataforthemajorityof patientswhoaredialyzedinpediatricdialysisunitsandincludingpediatric‐specificco‐ morbidities,andnotontheproposedregressionmethodology,whichhasflawswhen appliedtosuchasmallpopulationwithincompletedata. WerequestthatCMSworkwithleadersofthepediatricdialysiscommunitytoo considerananalysisthatwouldincludeallaspectsofthecostforpediatricdialysis patientstodetermineanappropriatepediatricCMA.Weanticipatethatsuchan analysiswillresultinamoreaccuratepediatricCMAthancurrentlyproposed,and bemoreinlinewithreimbursingactualcoststothecountry'svitalpediatricESRD facilities. CMSmaywanttoconsiderpostponingtheapplicationofthebundledpaymento systemtothepediatricpopulationuntilmoreaccuratedatacanbecollectedand theactualcostsofcaringforsuchavulnerablepopulationcanbeanalyzedin moredetailbyCMS. TheAcademyappreciatestheopportunitytoprovidecommentsontheproposedruleandlooks forwardtoworkingwithCMStoensurethattheESRDProspectivePaymentSystem accommodatestheuniqueaspectsofhealthcareservicesdeliveredtochildren. Sincerel ,

JudithS.Palfrey,MD,FAAP President JSP/sk