“[Dialysis patients] can be on 8 to 15 medications, depending on their comorbid conditions,” says Cellini. “They could have multiple physicians prescribing them.”

Dialysis patients are also prone to frequent hospitalizations, adding on to the difficulty of managing the complete medication profile. Cellini says physician, staff and patient education throughout the implementation of the new PPS will prove to be crucial in the coming months.

Patient advocacy groups also expressed concern about the inclusion of Part D drugs into the bundled payment. Dialysis Patient Citizens, a Washington D.C.-based nonprofit advocacy group with more than 22,000 members, is glad CMS delayed the inclusion of the drugs until 2014 but some worries persist.

“How will the system actually work?” asks Chad Lennox, the organization’s executive director. “Many dialysis patients are lower-income and some have mobility issues. Some of the smaller providers will have to contract with local pharmacies and there’s been some concern that patients won’t be able to get the medications as easily as they could before. Would they be dealing with multiple pharmacists?”

There are also some qualms about pharmaceutical innovation. If there is a set price on the drugs, there’s less of an incentive for pharmaceutical companies to invest in the research and development that’s necessary to produce the next generation of drugs, says Lennox.

Oral drugs with injectable equivalents are a different story. Those will be included in the bundle starting Jan.1 of next year. CMS classified the products into five different ESRD drug categories, with the intention of offering flexibility to incorporate new drugs into the bundle as they become available.

A pricey transition
Providers already knew that they were going to get hit with a 2 percent cut in reimbursement as mandated by Congress in MIPPA of 2008, but an additional reduction as a result of a CMS calculation came as a surprise. In an effort to maintain budget neutrality, the agency is shaving off 3.1 percent from payments to all clinics in the first year of the transition to the new bundled system, affecting even those facilities that decide to fully opt-in starting next year.

In the final rule, CMS estimates 57 percent of facilities will choose to transition to the new PPS over a four-year period, and thus receive a blended payment rate during the transition. The agency projects the remaining 43 percent of providers will choose the more immediate opt-in option. To compensate for the agency’s assumption that less than 50 percent of providers will opt-in, CMS is reducing payments by the previously mentioned 3.1 percent.

More Industry Headlines