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Dialysis Specific Provisions of ObamaCare

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Jack Ahern, MBA


Happy Spring! As we march into March and celebrate St. Patrick's Day it is clear that despite the largely symbolic attempt on Jan. 19 by House Republicans to repeal ObamaCare, the President's healthcare plan stands firmly as the law of the land-Public Law No: 111-148.

Last month I addressed the far reaching impact of ObamaCare a.k.a. H.R. 3590 or the Patient Protection and Affordable Care Act (PPACA). I noted that, as healthcare professionals, the PPACA affects us in a threefold manner: as healthcare providers, purchasers and as potential patients.

With respect to reimbursement, as healthcare providers, we are in essence, sub-contractors to health insurers, be they commercial or government sponsored. Moreover, as employers and employees, we must purchase healthcare insurance. Finally, when disease strikes and we become patients, we consume the very healthcare resources we produce. To illustrate the broad impact of ObamaCare, I presented from the official summary of the PPACA, a diverse set items regulated and mandated by ObamaCare. This month I will focus on sections 3202 and 10336 of the PPACA which directly reference dialysis.

Section 3202 limits co-pays and deductibles for Medicare HMO/managed care patients, this may be of importance for those providers with a significant volume of Medicare managed Care patients, especially if the present terms of reimbursement charge more to the patient than they would pay under traditional Medicare. The following are the exact words of the provision.

SEC. 3202. BENEFIT PROTECTION AND SIMPLIFICATION.

(a) LIMITATION ON VARIATION OF COST SHARING FOR CERTAIN BENEFITS-Patient Protection and Affordable Care Act - SEC. 3202. BENEFIT PROTECTION AND SIMPLIFICATION.

(a) LIMITATION ON VARIATION OF COST SHARING FOR CERTAIN BENEFITS.-Section 3202 prohibits Medicare Advantage plans "from charging beneficiaries cost sharing for chemotherapy administration services, renal dialysis services, or skilled nursing care that is greater than what is charged under the traditional fee-for-service program." The effective date for this requirement is for plan years beginning on or after Jan. 1, 2011.

Section 10336 might surprise some readers who thought the new bundle was a done deal, because it leaves room for further modifications, albeit, not for a year or so.

SEC. 10336. GAO STUDY AND REPORT ON MEDICARE BENEFICIARY ACCESS TO HIGH-QUALITY DIALYSIS SERVICES.

Per the official summary, section 10336 "Directs the Comptroller General to study and report to Congress on the impact on Medicare beneficiary access to high-quality dialysis services of including specified oral drugs furnished to them for the treatment of end-stage renal disease in the related bundled prospective payment system."

It is well worth the time to peruse the complete detailed text of this PPACA section.

(a) STUDY-(1) IN GENERAL-The Comptroller General of the United States shall conduct a study on the impact on Medicare beneficiary access to high-quality dialysis services of including specified oral drugs that are furnished to such beneficiaries for the treatment of end-stage renal disease in the bundled prospective payment system under section 1881(b)(14) of the Social Security Act (42 U.S.C. 1395rr(b)(14)) (pursuant to the proposed rule published by the Secretary of Health and Human Services in the Federal Register on September 29, 2009 (74 Fed. Reg. 49922 et seq.)). Such study shall include an analysis of-(A) the ability of providers of services and renal dialysis facilities to furnish specified oral drugs or arrange for the provision of such drugs; (B) the ability of providers of services and renal dialysis facilities to comply, if necessary, with applicable State laws (such as State pharmacy licensure requirements) in order to furnish specified oral drugs; (C) whether appropriate quality measures exist to safeguard care for Medicare beneficiaries being furnished specified oral drugs by providers of services and renal dialysis facilities; and (D) other areas determined appropriate by the Comptroller General.

(2) SPECIFIED ORAL DRUG DEFINED.-For purposes of paragraph (1), the term "specified oral drug" means a drug or biological for which there is no injectable equivalent (or other non-oral form of administration). (b) REPORT.-Not later than 1 year after the date of the enactment of this Act, the Comptroller General of the United States shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate. [Emphasis Added]

I leave it to the reader to draw his or her own conclusions regarding the above two sections of the ObamaCare legislation. However, it could not be more clear that the new dialysis bundle will be subject to close scrutiny and dialysis providers should keep well apprised of what substantial recommendations, if any, the GAO report has for Congress. It should also be noted that the GAO report will be issued as the next presidential campaign heats up.

So, will the GAO report impact ESRD payment? As always, I invite you to send me your comments at jahern@ ahernconsulting.com and let me know what you think!

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Jack Ahern, MBA - As a seasoned Healthcare Executive, Instructor, Author and Financial Manager, Jack Ahern brings to the table expertise gained by managing finances for an academic medical center, and providing guidance to physicians, hospitals, HMO's and major academic medical centers on issues pertaining to physician and hospital billing, hospital administration, strategic planning, renal dialysis reimbursement, HIPAA, ethics, regulatory issues and compliance.

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