Policy Priorities

1. Maintain Access to Private Health Insurance in the Health Exchange for Individuals with ESRD

   KCP supports insurance parity and coverage of treatment for individuals with End Stage Renal Disease (ESRD) who purchase insurance through the Health Insurance Exchanges (Exchanges). Individuals who develop kidney failure while having coverage through a Health Insurance Exchange plan should be treated the same as those who have similar private coverage outside the Exchanges today. This parity would mean that individuals in the Exchanges would have the ability to maintain their private coverage for thirty months after their diagnoses with kidney failure, a diagnosis that makes them eligible for Medicare. The Department of Health and Human Services (HHS) clarified in the Final Rule on the Establishment of Exchanges and Qualified Health Plans (CMS-9989-F) that MSP rules apply in the small group market. The relevant portion of the regulation is as follows: "We clarify that QHPs offered in the small group market fall under the definition of a group health plan subject to MSP provisions codified in section 1862(b)(1) of the Social Security Act. This would result in parity between the SHOP and non-Exchange small group market regarding the applicability of MSP rules that pertain to ESRD coverage."

   In addition, given the importance of private coverage to this population, the Center for Consumer Information and Insurance Oversight (CCIIO) should maintain the federal commitment to Americans living with kidney failure by ensuring that coverage for ESRD is expressly included as an essential health benefit. It is critically important that there is no misunderstanding that Americans with life-threatening kidney failure have access to coverage for ESRD in plans offered through the Exchanges.
   
   Issue Brief: Maintain Access to Private Health Insurance in the Health Exchanges
   
   Policy Documents:

   1. Final Rule on the Establishment of Exchanges and Qualified Health Plans (CMS-9989-F)
   2. Senate Letter to Secretary Sebelius on MSP in the Exchanges
   3. KCP Comment Letter on the Essential Health Benefits Bulletin
   4. CCIIO Essential Health Benefits Bulletin
   5. Business Round Table Letter to CCIIO Director Steve Larsen
   6. US Chamber Letter to CCIIO Director Steve Larsen
   7. NKF Letter to CCIIO Director Steve Larsen

2. Protect Life-Sustaining Dialysis Care from Payment Reductions

   

   The kidney care community serves a highly vulnerable, largely Medicare and dually eligible patient population. Public program reimbursement overall is declining just as the Medicare End Stage Renal Disease (ESRD) program transitions into a new prospective payment system. The pressures on the Medicare ESRD program have been growing. Dialysis facilities have been subject to a 2% payment cut under the new bundled payment system. Under the Quality Incentive Program (QIP) 30% of dialysis facilities have had their payments reduced by up to 2%. In addition, Congress has recently enacted reductions in Medicare payments, such as the decrease in Medicare bad debt payments and the 2% sequestration adjustment, that affect dialysis facilities.
   
   More than 80% of dialysis patients are Medicare beneficiaries, because in 1972, Congress committed to provide access to life-sustaining dialysis treatments for individuals through the Medicare program, regardless of age. Because of this unique entitlement, dialysis facilities have no ability to alter payer mix. Further cutbacks in Medicare payments could put patient access to care at greater risk.
   
   Congress should maintain its commitment to the nearly 400,000 Americans with irreversible kidney failure and oppose additional payment cuts that could compromise access to this life-saving treatment.
   
   Issue Brief: Protect Life-Sustaining Dialysis Care from Payment Reductions
   Slide Presentation: Protect Dialysis Care from Payment Reductions
   
   Policy Documents:

   1. KCP Letter to the Joint Select Committee on Deficit Reduction
   2. ASN/ASPN/RPA Letter to the Joint Select Committee on Deficit Reduction
   3. Patient Group Letter to the Joint Select Committee on Deficit Reduction

4. Ensure Proper Implementation of the ESRD Prospective Payment

   The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) required that the Secretary of the Department of Health and Human Services implement a bundled payment policy for dialysis services beginning on January 1, 2011. The Centers for Medicare and Medicaid (CMS) issued the first ESRD PPS Proposed Rule on September 15, 2009, which outlined the new Medicare payment system for dialysis facilities. As the dialysis community's only broad-based coalition of kidney patient advocacy groups, health care professional organizations, and dialysis service providers and suppliers, KCP submitted comments to the Agency and continues to work with CMS as it refines the program to ensure that implementation of the bundled payment system does not result in unintended consequences that adversely affect the quality of care for dialysis patients.
   
   Policy Documents:

   1. KCP Summary of ESRD CY 2013 PPS Proposed Rule
   2. KCP Comment Letter on ESRD PPS CY 2012, ESRD
      QIP PY 2013 and 2014 Proposed Rule
   3. ESRD PPS for CY 2012, ESRD QIP for PY 2013 and PY 2014 Final Rule
   4. ESRD PPS for CY 2012, ESRD QIP for PY 2013 and PY 2014 Proposed Rule
   5. KCP Statement on Interim Final Rule on Changes to the ESRD Prospective Payment System Transition Budget-Neutrality Adjustment
   6. Interim Final Rule on Changes to the ESRD Prospective Payment System Transition Budget-Neutrality Adjustment
   7. KCP Comment Letter to CMS on ESRD PPS for CY 2011 Proposed Rule
   8. KCP Comment Letter on ESRD PPS for CY 2011 Final Rule
   9. KCP ESRD PPS for CY 2011 Final Rule Summary
   10. ESRD PPS for CY 2013, ESRD QIP for PY 2014 and PY 2015, and Bad Debt Reductions for all Medicare Providers Proposed Rule (CMS-1352-P)

5. Ensure ESRD Quality Incentive Program Accurately Assesses Care Provided to Medicare Beneficiaries

   KCP is strongly committed to implementing a value-based purchasing system within the Medicare ESRD program. Such a program is consistent with ongoing efforts through the Kidney Care Quality Initiative (KCQI). The first payment reductions related to the QIP for dialysis providers and facilities took affect on January 1, 2012. KCP continues to work with CMS to ensure that this penalty-based system is structured to accurately and effectively evaluate the care provided to beneficiaries receiving life-sustaining dialysis treatments.
   
   Policy Documents:

   1. KCP Comment Letter on ESRD PPS CY 2013, ESRD QIP PY 2014 and 2015 Proposed Rule
   2. ESRD PPS for CY 2012, ESRD QIP for PY 2013 and PY 2014 Final Rule
   3. KCP Summary of ESRD PY 2014 and PY 2015 QIP Proposed Rule
   4. KCP Comment Letter on ESRD PPS CY 2012, ESRD QIP PY 2013
      and 2014 Proposed Rule
   5. ESRD PPS for CY 2012, ESRD QIP for PY 2013 and PY 2014 Proposed Rule
   6. KCP ESRD QIP Final Rule Summary
   7. KCP Comment Letter on ESRD Quality Incentive Program for PY 2012 Proposed Rule
   8. ESRD PPS for CY 2013, ESRD QIP for PY 2014 and PY 2015, and Bad Debt Reductions for all Medicare Providers Proposed Rule (CMS-1352-P)

    

6. Ensure Access to Medically Necessary Treatment Options

   • National Coverage Decision for ESAs:
     In 2010, CMS initiated a national coverage analysis (NCA) for ESAs for treatment of anemia in adults with CKD including patients on dialysis and patients not on dialysis. The Agency concluded that an national coverage determination was not warranted at that time.  KCP remains committed to ensuring that Medicare supports medically necessary treatment options for beneficiaries with kidney failures, especially those related to anemia management.
     
     Policy Documents:
     1. KCP Comment Letter on Proposed Decision Memo
     2. CMS Proposed Decision Memo
     3. KCP Congressional Testimony on Ensuring Kidney Patients Receive Safe and Appropriate Anemia Management Care
        
   • ESA Monitoring Policy
     On July 20, 2007, the Centers for Medicare and Medicaid Services (CMS) announced changes to its policy entitled "Monitoring of Erythropoietin Stimulating Agents (ESA) for Beneficiaries with End Stage Renal Disease." KCP appreciated the Agency's efforts to implement an appropriate policy to address proper ESA dosing for ESRD patients. We emphasized the need to ensure that the Agency's policies do not result in adverse outcomes for Medicare beneficiaries.
     
     Policy Documents:
     1. KCP Comment Letter to CMS on the ESA Monitoring Policy
     2. CMS ESA Monitoring Policy

1. ESA Monitoring Policy
   On July 20, 2007, the Centers for Medicare and Medicaid Services (CMS) announced changes to its policy entitled "Monitoring of Erythropoietin Stimulating Agents (ESA) for Beneficiaries with End Stage Renal Disease." KCP appreciated the Agency's efforts to implement an appropriate policy to address proper ESA dosing for ESRD patients. We emphasized the need to ensure that the Agency's policies do not result in adverse outcomes for Medicare beneficiaries.
   
   Policy Documents:
   KCP Comment Letter to CMS on the ESA Monitoring Policy
   CMS ESA Monitoring Policy

    

8. Extend Immunosuppressive Drug Coverage

   While there is no cure for ESRD, a kidney transplant is often the treatment option associated with the best outcomes for patients. Patients who receive a kidney transplant must take anti-rejection or immunosuppressive drugs for the life of their kidney transplant. However, Medicare will only pay for these drugs for the first thirty-six months after a patient receives their transplant. These medications average $17,000 per year. Patients who are unable to pay for the medications are often forced to discontinue their use, resulting in kidney rejection and a return to Medicare-covered dialysis treatments at an annual cost of more than $82,000 per patient.

   KCP supports efforts to fund the vital coverage for immunosuppressive drugs, but not at the expense of patients receiving dialysis treatments. Rather than fund this expansion of coverage through cuts to the reimbursement rates for dialysis, KCP recommended extending the Medicare Secondary Payor (MSP) provision. The MSP extension raises revenue of approximately $1.2 billion that would cover the cost of immunosuppressive drugs and also provide dialysis patients who wish to continue to rely on their private insurance coverage the ability to do so. Within the Medicare Program, patients on dialysis are the only beneficiaries who are forced to give up their private insurance coverage because of the diagnosis of a disease. 
   
   Policy Documents:
   KCP Response to CJSAN Article on Immunosuppressive Drug Coverage

    

7. Improve Access to Patient CKD Education

   KCP spent several years seeking to obtain coverage and reimbursement for education sessions for Medicare beneficiaries with chronic kidney disease. We worked closely with Members of Congress to encourage the inclusion, and ultimately the passage, of such provisions in the Medicare Improvements for Patients and Providers Act (MIPPA). Effective educational intervention is critical to informed decision-making, effective management of co-morbidities and uremic complications, and enhanced patient participation in their own health care. We also believe that effective education has the potential to delay the onset of dialysis, resulting in improved quality of life and reduced costs to the Medicare program. KCP continues to work with Congress and CMS to refine and improve access to this important patient benefit.
   
   Policy Documents:

   1. KCP Comment Letter to CMS on the Physician Fee Schedule Proposed Rule
   2. CY 2012 Physician Fee Schedule Proposed Rule

3. Support the Kidney Disease Equitable Access, Prevention,
   and Research Act (S.2163/H.R. 6011)

   Background:
   Just a half-century ago, there was no treatment for irreversible kidney failure, also known as End Stage Renal Disease (ESRD). To ensure that all individuals with kidney failure had access to dialysis, a treatment developed in the 1960s, Congress in 1972 committed to provide Americans with kidney failure with coverage for their lifesaving therapy through the Medicare program. Kidney failure is fatal unless a patient receives either a transplant or dialysis, and the vast majority of patients undergo lengthy dialysis treatments three times a week. Today, approximately 400,000 Americans have ESRD.

   The Problem:
   Congress took critical steps to ensure quality dialysis care in the Medicare Improvements for Patients and Providers Act (MIPPA) by establishing a new "bundled" ESRD Prospective Payment System (PPS) and creating Medicare's first value-based purchasing program. Congress should continue to build upon its efforts to preserve quality care for ESRD patients.

   The Solution:
   The Kidney Disease Equitable Access, Prevention, and Research Act (S.2163/H.R. 6011) The members of the kidney care community have joined their voices once again to improve the Medicare ESRD benefit so that it promotes prevention, research, and equitable access. The "Kidney Disease Equitable Access, Prevention, and Research Act of 2012" would:

   • Improve the kidney disease education benefit by: (1) extending it to individuals diagnosed with late-stage kidney failure who current cannot access the 6-session benefit; and (2) expanding the types of providers who can offer it to beneficiaries;
   • Require the Secretary of Health and Human Services to research and report on: (1) gaps in quality and care management metrics; and (2) factors that affect care and the barriers to improving health and reducing disparities among minority populations;
   • Have the GAO make recommendations as to how to reduce transportation barriers that threaten beneficiary access to care;
   • Address regulatory barriers that make it more difficult to access dialysis care; and
   • Extend patient choice of insurers and provide insurance parity and protections for Americans with kidney failure.

   The House bill also allows enrollees with ESRD to maintain access to premium and cost-sharing subsidies available to assist in purchasing health insurance coverage in the health insurance exchanges after the diagnosis of kidney failure.

   Issue Brief: Kidney Disease Equitable Access, Prevention,
   and Research Act ((S. 2163/H.R. 6011)
   
   Policy Documents:

   1. Section by Section Summary of H.R. 6011 document
   2. Section by Section Summary of S. 2163
   3. Senate Bill: The Kidney Disease Equitable Access, Prevention, and Research
      Act of 2012 (S.2163)  
   4. House Bill: The Kidney Disease Equitable Access, Prevention, and Research Act of 2012 (H.R. 6011)

   Kidney Disease Legislation - History
   

   • MIPPA  
   • KCQEA

    

Performance, Excellence, and Accountability in Kidney Care (PEAK) is a voluntary quality improvement campaign to reduce mortality among first-year dialysis patients by 20 percent by the end of 2012—an effort to extend, even save, 10,000 lives. Working with researchers and other experts in the kidney care community—and partnering with Brown University and Quality Partners of Rhode Island—the PEAK Campaign has identified and shared patient and family engagement best practices, as well as clinical/technical best practices, and is monitoring quarterly progress toward the goal

Kidney Care Quality Initiative (KCQI)
To assist policymakers, KCP formed the Kidney Care Quality Initiative (KCQI) to develop a well-designed continuous quality improvement program that meets the needs of patients, other members of the kidney care community, and federal policymakers. The KCQI, through the Kidney Care Quality Alliance, also developed and tested performance measures that were endorsed by the NQF in the areas vascular access, patient education, and influenza immunization.