text:
Download the Album
The entire Maverick Rising project, including FLAC and MP3 format audio files as well as album artwork, trailer, and exclusive bonus tracks, can be downloaded using BitTorrent. If you need help with using BitTorrent, please refer to https://bt.ocremix.org.
Download Torrent (2.83GB)
To download the MP3s & album art only (521MB), right-click & save the ZIP file.
To download individual MP3s, visit the Music section.
To download the album art, visit the Album Art section.
SHARE THE ALBUM! Tweet
FOLLOW OC REMIX! Follow
In 1993, Mega Man came to 16-bit for the first time, and with it some of the most ambitious and successful video game music on the SNES. The series carried on over the years and across several platforms, and the fantastic soundtracks prevailed alongside. OverClocked ReMix finally celebrates and pays homage to the series and its cutting edge soundtrack with their 33rd album project, Maverick Rising. With 5 discs loaded with heart-pounding, controller-gripping tracks, this album is sure to make anybody who's ever had contact with the Mega Man X series of games brim with joy. Download the album and become part of this incredible project today!
Director: Bahamut
Assistant Director: Level 99
Website/Trailer: Drew Gourley
Assistant Director: Emunator
Album Art: Dominic Ninmark
Trailer: José the Bronx Rican
This album is freely available online and is not being distributed for profit. It was made by fans, for fans, and is not affiliated with or endorsed by the developers or publishers that have produced the referenced titles.
This album's goal is to help promote video game music, the original composers, and the talented artists that contributed to this project. We encourage you to enjoy this music and share it freely while complying with the terms of the OverClocked ReMix Content Policy.
All images, characters, and original compositions are copyright their respective owners.
Founded in 1999, OverClocked ReMix is an organization dedicated to the appreciation and promotion of video game music as an art form. Its primary focus is ocremix.org, a website featuring thousands of free fan arrangements, information on game music and composers, resources for aspiring artists, and a thriving community of video game music fans.
© 21XX OverClocked ReMix
All images, characters, and original
compositions from Maverick Rising
are copyright their respective owners.
Arrangements are available under the
OverClocked ReMix Content Policy
Site design by Drew Gourley
Share Maverick Rising!
Follow OC ReMix!


text:
Browse Used Cars in Clarksville, TN
Clarksville, TN Cars
Cheap Cars for Sale in Clarksville, TN Save $3,711 on 325 Deals
Cars for Sale by Owner in Clarksville, TN Save $4,324 on 5 Deals
Browse Makes in Clarksville, TN
Used Audi in Clarksville, TN Save $11,900 on 63 Deals
Used Cadillac in Clarksville, TN Save $8,306 on 49 Deals
Used Chevrolet in Clarksville, TN Save $8,046 on 315 Deals
Used Dodge in Clarksville, TN Save $6,464 on 110 Deals
Used Ford in Clarksville, TN Save $16,150 on 475 Deals
Used Honda in Clarksville, TN Save $5,254 on 219 Deals
Used Lexus in Clarksville, TN Save $6,743 on 62 Deals
Used Mazda in Clarksville, TN Save $4,620 on 49 Deals
Used Nissan in Clarksville, TN Save $8,137 on 324 Deals
Used Toyota in Clarksville, TN Save $8,514 on 262 Deals
Browse Cars in Clarksville, TN by Price Range
Used Cars Under $10,000 in Clarksville Save $4,231 on 412 Deals
Used Cars Under $16,000 in Clarksville Save $5,004 on 1,119 Deals
Used Cars Under $2,500 in Clarksville Save $972 on 2 Deals
Used Cars Under $3,000 in Clarksville Save $1,633 on 3 Deals
Used Cars Under $4,000 in Clarksville Save $1,860 on 12 Deals
Used Cars Under $40,000 in Clarksville Save $10,756 on 5,712 Deals
Used Cars Under $7,000 in Clarksville Save $3,558 on 153 Deals
Cheaps Cars by Type in Clarksville
Cheap SUV in Clarksville, TN Save $25,927 on 1,196 Deals
Cheap Trucks in Clarksville, TN Save $14,441 on 466 Deals
Used Convertibles in Clarksville, TN Save $27,122 on 170 Deals
Used Minivans in Clarksville, TN Save $7,002 on 253 Deals
Used SUV in Clarksville, TN Save $48,713 on 2,563 Deals
Used Trucks in Clarksville, TN Save $14,441 on 466 Deals
Used Vans in Clarksville, TN Save $8,809 on 38 Deals
Browse Clarksville, TN Cars by Market Segment
Exotic Cars for Sale in Clarksville, TN Save $48,713 on 39 Deals
Luxury Cars for Sale in Clarksville, TN Save $48,713 on 1,664 Deals
Muscle Cars for Sale in Clarksville, TN Save $14,023 on 256 Deals
Sports Cars for Sale in Clarksville, TN Save $34,151 on 867 Deals
Popular Searches in Clarksville, TN
Used Hybrid Cars in Clarksville, TN Save $8,514 on 230 Deals
Used Diesel Cars in Clarksville, TN Save $16,252 on 123 Deals
Used Electric Cars in Clarksville, TN Save $20,907 on 475 Deals
Used Manual Transmission Cars in Clarksville, TN Save $12,927 on 300 Deals
Popular Truck Searches in Clarksville, TN
Used Diesel Trucks in Clarksville, TN Save $9,773 on 81 Deals
Used Trucks Under $5,000 in Clarksville Save $1,417 on 4 Deals
Used Trucks Under $10,000 in Clarksville Save $3,705 on 17 Deals
Browse Clarksville, TN Cars by Engine
4-Cylinder Vehicles Clarksville, TN

redpajama_set_name: RedPajamaCommonCrawl


text:
Q: localStorage problem in apollo authorization header in NextJS and React I use this solution to use apollo client in my NextJS and React project.
Why I can't use localStorage in withApollo.js?
I run this code:
import withApollo from 'next-with-apollo';`
import ApolloClient, { InMemoryCache } from 'apollo-boost';
import { ApolloProvider } from '@apollo/react-hooks';

export default withApollo(
  ({ initialState }) => {
    return new ApolloClient({
      uri: 'http://localhost:8000/graphql/',
      cache: new InMemoryCache().restore(initialState || {}),
      headers: {
        authorization: localStorage.getItem("token")
      }
    });
  },
  {
    render: ({ Page, props }) => {
      return (
        <ApolloProvider client={props.apollo}>
          <Page {...props} />
        </ApolloProvider>
      );
    }
  }
);

and I see this error:
ReferenceError: localStorage is not defined
module.exports../lib/withApollo.js.__webpack_exports__.default.next_with_apollo__WEBPACK_IMPORTED_MODULE_1___default.render.Page.Page ./lib/withApollo.js:11

Can you help me?

redpajama_set_name: RedPajamaStackExchange


Note: This is my first blog post in quite awhile. The past year has been rough. My first blog post is about All Saints' Day, one of my favorite liturgies of the year.
All Saints' is one of my favorite liturgies of the year.
I was ordained in 2000 around All Saints Day so I could intentionally invoke the saints past and present into my ordination liturgy. I value remembering the dead and their role in our lives. I love weaving baptism and communion around the Saints, pulling their names into the present and invoking our God of past, present, and future.
It's been a hard year at Pilgrims with the death and dying of our former pastor, Jeff Krehbiel. This seemed like an important liturgy for us to be close together, like a communal, liturgical hug.
To create a liturgical hug, we did some re-arranging of our space and wove in both baptism and communion to the liturgy.
Pilgrims sanctuary was re-designed in the early 2000's to be more flexible and to fit our size (read: we don't have 500 people in worship like in the 1950's). We have capability to improvise with our space, making it fit not only the liturgical story we are sharing but also Pilgrims story of who we are today.
You can see below our usual set-up. Our side pews usually have few people (who wants to sit up front?!) and most people sit in the main two sections of pews in the middle of the sanctuary (where you see the pews with "people"). This works for us and yet we can still be spread out.
Several months ago we moved the piano which was way in the back up to where it is now in the "typical set-up." In moving the piano, we wanted Billy Kluttz, our music director, closer to us to strengthen and support our singing (sometimes it's hard to sing out when one is sad and grieving).
On All Saints, we used those red rope things that churches use to block off pews to move everyone forward.
You can in the design below that we had people sitting in only the first two set of pews in the main, middle section. We moved a few chairs in front of the right side pews to help give some shape to that open space.
People sait in the front pews that face towards each other. We moved the communion table back and placed the font (usually the entrance of the sanctuary) on the table. Our font has a large, glass removable bowl that allows us this flexibility.
hear each other singing. We built off each other's voices to sing with more strength and energy.
the space felt more incarnational, as if we were the Word made flesh because we were closer to each other.
I've got a bee in my bonnet these days about baptism, death, and resurrection. In the services of life and resurrection, the language goes that in death one's baptism has been complete.
In our tradition, baptism, the sacrament of belonging, is experienced in community. As part of the baptism liturgy, those gathered re-affirm their own baptisms. Around the font, the Spirit gathers up and connects all of our baptisms. At the font, baptism becomes incarnational and we proclaim in the waters of baptism we die to the ways of empire and evil and live into the ways of Christ. We enter into the mystery of death and new life and that mystery is always available.
In death the physical body dies. Yet we trust that there will be resurrection and that resurrection includes the vows of baptism. Those vows come back to us in our lives, in our community. Those vows come back to us as we continue to gather around the font and break bread around the table. When we walk away from the waters of the font, we are empowered, as people of life and death, to do the Jesus work of feeding, healing, and raising the dead and raising-up the baptism of the dead.
For me, to say that baptism is complete in physical death is a Western, individualized way of seeing baptism. As if all along we've been living our baptisms individually and baptism doesn't have the power to transcend physical death.
So....with that bee in my bonnet.....I wrote baptism into our litany of saints. Several us read this litany and one of our 4-year old Pilgrims helped me pour water into the font at the appropriate time. Our giant glass font was on the communion table throughout the service (see space layout above).
Throughout this litany of Pilgrim Saints, Billy will lead us in an alleluia.
We sing an alleluia to remember that the women at Jesus' tomb taught us that even at the grave we sing God's alleluia.
Water will also be poured into the font during the alleluias, reminding us of the baptisms of our saints, that even in death, the spirit of their baptisms is never ending, for their baptismal vows made in Christian community live on in us.
By faith, let us remember our own Great Cloud of Witnesses, as their spirits and work continue to be a source of life for us today.
Eternal God, our help in ages past, our hope for years to come, we praise you for the saints of all times and places who have walked the road of faith before us and beside us.
God of ages past, we remember our our ministers and clergy who worked off each other legacies, who shared their lifeblood with this Pilgrim community and are now bound together in Your Great Cloud of Witnesses.
By faith, we remember Pilgrims Ministers of Music: Warren Johnson, Dexter Davidson and James Boeringer. We remember their gift of creating prophetic community through music that we build upon today.
By faith, we remember our founding pastors, Benjamin Franklin Bedinger, Harrison Waddell Pratt and Andrew Reid Bird, who were led by God to build this community of faith out of nothing but faith.
By faith, we remember J. Randolph Taylor, Herb Meza, Sid Skirvin, and Jeffrey Krehbiel who as pastors led this congregation in faithful new directions with their vision for radical peace and justice. Let us give God thanks and praise for these Pilgrim saints.
God of all creation, we praise you for all your disciples who have witnessed to your truth, who have shown us your love, who have inspired us to have hope.
After the litany and adapted version of Hebrews 11, we lit candles of those who have died and shared the bread and cup.


541 posts categorized "Writer: Bill Peckham"
I am busy being retired and getting fit. Coming up on the start of my 29th year using hemodialysis and I have recommitted to seeing how far I can take relying on a a medical procedure to replace renal function. I have a new project that I am excited about but want to get DTS up and going before talking too much it.
My hands are not what they use to be, I can't make a fist or snap my fingers. It hurts to type and use a mouse after just a short time at the computer. My hand's weakness and pain with use is why I retired from the Union on a disability pension. I can't make signs for more than a couple hours and sitting at a computer - moving to the office side of the business - left me feeling worse. Disability retirement could be temporary but work would have to fit the life I have designed and look forward to.
SEN will have posts - I will have one (or several) posts on pain and the treatment of pain just not very often. I don't feel video discussions are really in my swing space - I'd need a producer. Twitter however, has been a good fit. The nephrology Twitter community is fun and interesting to interact with, give it a try and follow me @BillPeckham I like the constraint and the brevity of 140 characters but when needed I like being able to post longer commentary as a thread. Check it out.
My right hand is numb so time to stop. Hope to see you on twitter, occasionally here and soon through DTS.
It is hard to discuss the hundreds of thousands dialyzing incenter who do not want a transplant, and who do not want to dialyze at home, and will not extend treatments. Do they have a voice? are their voices welcome? Peter and I are not the ones to speak for them but I know they're there; I don't hear their voices.
My last SEN Talk with Dr Hippen caused me to reflect on the big picture of kidney care. The problem goes beyond silos. If there were no silos dividing dialysis from transplant, early stage CKD from Stage5, there would still be the issue that a plurality (*if not majority) of people with Stage5 choose to dialyze incenter, conventionally. *700,000 people in the US have CKD5: 200,000 with transplant/500,000 using dialysis. The 500,000 dialyzors are 90% incenter/10% home. Account for the 100,000 ish people dialyzing incenter who are or want to be listed for a transplant and still >350,000 are incenter to stay.
I'm finding it hard to focus discussions in on this group of dialyzors: the enduring plurality of people treating their CKD5 with dialysis in a way no nephrologist would accept. That's the incenter hemodialysis problem.
Dr Hippen (writings, LinkedIn interview) talks with me about the need to integrate kidney transplant care into comprehensive care models, risk and what patient-centered means in the kidney transplant context.
Hippen's AJT is article is here. One if these days he and I should do a SEN Talk just on transplant v dialysis cost numbers.
Henning Søndergaard in Copenhagen joins me for SEN Talk3. He describes a self-care dialysis unit that is patient-centered beyond what is usually proposed in the United States. I know of Hui Laulima o Hana Maui (here, here) which operates as a shared space for home dialyzors but the Copenhagen example is self care taken to a new level.
Søndergaard's self care unit allows people 24/7 access to dialysis, they can schedule treatment times over the internet and let themselves in with their own key card. Every other day dialysis, and incenter nocturnal dialysis are treatment options. Really it is on demand dialysis.
Søndergaard's two part article for Nephrology News & Issues is here.
I can make myself feel uremic by decreasing my dose of dialysis. I can make myself feel unwell, struggle to walk up a flight of stairs, lose my appetite and my energy in general ... and then, incredibly, I can feel better by dialyzing a few nights in a row. This demonstration is repeatable by me and I suspect is one reason people who use home hemodialysis are among the kidney community's most active dialyzor advocates. We, who get enough dialysis, know dialysis can reverse the symptoms people often point to when talking about how they feel dialyzing incenter, three days a week.
I most recently induced uremia in myself last month after a week in London. (I retired last year and almost immediately developed a severe comorbidity - Hamiltonitise, which is marked by a compulsion to see the musical Hamilton. (It seems to be under control, I've seen each of the live productions and use the cast album as needed.)) I dialyzed incenter three times during the week and extended my weekend coming home, by the time I got back on my normal schedule I felt uremic. Hemodialysis works and dose matters. Patient-centered care has to include finding the best life/dialysis balance for each person.
This is the first official Sharp End of the Needle Talk - SEN Talk - that I will also publish as a podcast (assuming I figure out how). As an active advocate, volunteer and donor for and to kidney research I've had many conversations over the last 15 years that informed my advocacy and made me a more committed supporter. My goal with SEN Talks is to bring those conversations online.
Dr. Ann O'Hare is a professor of Medicine at the University of Washington, a researcher at the Kidney Research Institute and a practicing nephrologist at the Veterans Administration. I attended a recent Grand Rounds that she presented following on her AJKD article published last month Patient-Centered Care in Renal Medicine: Five Strategies to Meet the Challenge.
Patient-centered care and patient-centered research are seen as a way forward, a way of providing people who need dialysis "better care", which sounds good but what do we mean by "good care"? What makes care "better"? For this to work effort has to come from both directions, from providers and from the sharp end of the needle, from patients. It occured to me after we talked, that O'Hare's five strategies to provide patient-centered care: listening, making time, being willing to go beyond our job description, re-imagining what it means to provide "good" care, and seeing the value of relationship building could be repurposed into five strategies to receive self-centered care. Listening and relationship building are keystones to receiving self-centered care - be coachable - what other strategies should be included?
I hope this is just the first of an ongoing discussion with renal researchers and providers, how to create a more humane dialysis system both in the experience of dialysis and in the practice of dialysis. There are encouraging trends, but few people are satisfied with the provision of dialysis in the US writ large because we know it can be improved.
I thought I would reup some of my favorite DSEN posts over the holiday. Here is the first DSEN post, it's about traveling while using dialysis, but really it is about thriving while dialyzing. I was reminded when I read this that DSEN did have an agenda when the blog began; item one: to improve dialyzor access to international travel. Nothing ever came of it during DSEN's first 10 years but I haven't forgot. I'm looking forward to soon announcing a plan to facilitate international travel for we who do not pee.
This is the 1996 trip that started me on extensive travel while on dialysis. The following is an article I wrote for Nephrology News & Issues in March 1997, about my first trip to Europe. It was going on this trip that informs the First Agenda Item, the initial purpose of this blog. This trip kicked off 10 straight years of European and world travel - well over 100 dialysis treatments in 21 countries.
For six years I have scheduled in-center hemodialysis as part of golf vacations, long weekends, road trips, and assorted adventures. I do not let my end-stage renal disease determine the trips I take; I leave that to whim and opportunity. When the opportunity to travel abroad presented itself, my whim selected Europe.
On May 10, 1996 I left on an eight-week tour. In all I would visit eight countries of central and coastal Europe. I hopped night trains to Munich and the Metro to Versailles. I hiked in the Swiss Alps, and drove the Autobahn in Germany. I dined on linen draped tables in Carcassonne, while in Austria I picnicked in an alpine meadow. I saw the ancient and the new. I enjoyed myself from beginning to end.
I also had 23 dialysis treatments, from rural towns in Germany to center city Paris. They had to be coordinated as well with some planning.
I started putting the details together on my trip in January. The first step was to talk to Cheryl, the travel coordinator at my home dialysis unit. She gave me phone numbers for units in Europe and after I set up the appointments, Cheryl made sure each unit had the paperwork that they wanted. I used AT&T's translation service to set up my appointments. (Travel Tip: If I were doing it over, I would have sent more FAXES and made fewer phone calls. AT&T's translation service charges add up quick). I called each unit three times. I called the first time (end of January) for general information, the second time (early March) to schedule dates and times, and the last time (end of April) to make sure my paper work was in order. I also talked to my insurance provider and made sure I understood the details of being reimbursed. Unlike Medicare, which only covers dialysis in the continental United States, my insurance coverage as a union carpenter for GES Exhibition Services covers the cost for dialysis wherever I go.
The cost for dialysis treatments while traveling in Europe ranged from $354 in Germany to $447 in Paris. Over the eight-week trip, I spent about $9,000 in dialysis treatments. My erythropoietin prescription was followed at each facility. (Travel Tip:Let the facility know that you are paying for the dialysis. You may get a better rate).
From the start I used Rick Steves " . . . Through the Backdoor" travel guides to decide where to go, what to see, what to do, and how to do it. His books describe the traveler I want to be and the attitude I want to have. With a little planning, dialysis will not interfere with taking the sort of trip he describes in his books and on his PBS travel series. Instead of thinking of dialysis as an inconvenience, I came to see dialysis as a "Backdoor." Through this backdoor I saw a side of Europe not open to most travelers.
I arrived in Amsterdam with my Eurorail pass (nine days train travel and five days of car travel), one bag (it has straps so it can be carried like a pack), twenty-three dialysis appointments (at six units in four countries) and modest expectations. I had no hotel reservations but a friend in Germany was expecting me in a week. I started the trip by myself. If I am given the choice between going alone or not going, I will choose to travel alone every time. I used my dialysis cities as bases and made day or weekend trips to other destinations. Using Straubing as a base, I visited Bavarian Castles and spent a weekend in Prague. I traveled for four weeks, wandering Europe and following the advice of Rick Steves. I visited the Netherlands, Germany, the Czech Republic, Italy, Switzerland, and France. It was as fun as Rick said it would be and three times a week I'd visit my own European backdoor.
To start week five, I met my mother in Paris and we toured France from Dijon to Carcassonne. After a week, my girlfriend Theresa joined us. In Paris, Rick Steves endorses staying in the Rue Cler neighborhood, which is perfect for dialysis. A self-care unit is within easy walking distance. The local patients set-up their own machines but the set-up was done for me. While I dialyzed, my mom and/or Teresa could enjoy five hours of doing as they please, napping, trip planning, or shopping. Traveling can be an intense experience. I am not used to being around someone 24 hours a day, weeks on end, and neither was Theresa or my mother. Dialysis provided a regular opportunity to take a break from each other and gain perspective.
After Paris, Teresa and I spent 17 days winding our way back to Amsterdam. We used the same base cities for dialysis but did different things between treatments. We stayed in Gimmelwald instead of Interlaken; Venice instead of Verona; a weekend in Austria rather than a visit to Prague.
Going into a dialysis unit for treatments in a foreign land was a perfect opportunity to interact with the locals. I enjoyed watching the activity of each unit, noting the similarities and differences between them, and comparing them with dialysis in the U.S. All the units I visited followed my medical charts. Their machines could not always run at my high pump speed but they would run me as fast as possible. At each unit I asked what their treatment standards were and learned American standards are not universal. While I dialyzed I could ponder the effect culture has on how we treat illness. At home I run on an F80 kidney at a 450 pump speed.
Europeans would expect big and fast dialysis from Americans. The French and Germans prefer long slow dialysis and a smaller kidney. The French finesse the blood clean, the Germans take a workman-like approach. The Swiss prefer to run their patients between the different standards. They are neutral. And in the Netherlands? How long I dialyzed and at what pump speed was up to me. The Dutch expect people to be responsible for their own choices. All the units I dialyzed in compare well with dialysis units I have visited in the U.S. The concern of the staff was for the well being of the patient, only the details were different.
When it comes to payment, a dialysis unit in Straubing, Germany wanted a cash payment after each run, as did a unit in Lugano, Switzerland. All the other units take Visa. In Lugano, uniquely, you change into scrubs before you start. Everywhere food is available during treatment. The food ranged from bread in Paris to a three-course meal complete with beer or wine in Lyon. In Interlaken, Switzerland the food is free in the hospital cafeteria after you are done. The Amsterdam unit had the most comfortable chairs, Lyón the best food.
The language barrier made it a challenge to talk casually with the staff in some units but a few key phrases made getting hooked up and taken off go smoothly. In most of the units someone on the staff spoke at least some English, often fluently.
The last day of the trip, after 62 days of travel, Teresa and I were outside Amsterdam in Haarlem, packing to leave. I turned to her and said, grinning. "I could keep going. A month, maybe two or three. I would just have to stop at a laundromat." If the measure of a trip is that at the end you are not ready to leave, then this had been a great trip.
My next adventure? Possibly traveling from London to Rome in the fall, and hopefully the Olympics in Australia.
A dialysis unit, as much as any museum or café, is a window into another culture. In fact, dialysis enriches an important part of the travel experience. It guarantees you a look through a country's "Backdoor."
The PATIENT Act necessarily divides the kidney stakeholder community. S. 2065/H.R. 4143 enthrones two members of the kidney community as the central command point for dialysis patients to access their Medicare reimbursed health care services. The PATIENT Act crowns DaVita and Fresenius Medical Care (FMC) as responsible to the US polity for the care of dialysis patients. With the PATIENT Act Congress grants DaVita and FMC regency over the country's Medicare beneficiaries who rely on dialysis.
As the kidney dialysis/transplant rule setter in the United States Medicare has what we can all agree is a frustratingly slow process of consensus building around policy. Medicare's policy making seems to only move forward in fits and starts and then after all the talk and inclusion, Medicare will publish a rule that can seem like a royal decree. But even then we who rely on dialysis know that there is a process, a process that greatly values our voices, the voices at the sharp end of the needle. As frustrating as Medicare's process can be it has helped to keep our kidney community united through some profound changes because the process allowed all stakeholders the opportunity to be a part of dialysis policy making.
Congress should cast the PATIENT Act aside. Rather than incapacitate Medicare's rightful role by passing a far reaching law that divides the kidney community, Congress should focus on legislation that would unite the kidney community. Listen to the stories of the people who use dialysis and transplant to treat their severe kidney disease, listen to the people who love us and help us care for ourselves. When our voices are in harmony then Congress can feel confident in legislating to improve our care. When there is dissonance, when the kidney community is divided, when beneficiaries hold opposing views, then Congress should step back.
The PATIENT Act grants a vicarious regulatory authority to DaVita and FMC that rightly rests with Medicare. The PATIENT Act constrains Medicare's ability to work with beneficiaries on new payment structures. The PATIENT Act divides the kidney community. The PATIENT Act is bad Medicine.
And they have partnered with a consortium of nonprofit, for-profit and advocacy groups for home dialysis to launch a website www.stopthemacs.com to advocate for fair payment for more than the 13 treatments/month that Medicare is ordinarily willing to reimburse.
The benefits of more frequent hemodialysis are clear to the people who pay the most to use it - the dialyzor and the people who love us. Dialysis providers must be fairly reimbursed for the services they provide both as a matter of fairness and because without fair payment dialyzors are at risk of losing access to their preferred treatment option. Not to mention the untallied many who will never know what they are sorely missing. However, to be fair the MACs have a point, which is not a secret. What is needed is legislation to direct Medicare to fix the problem.
To amend title XVIII of the Social Security Act to provide for payment under the Medicare Program for more frequent hemodialysis treatments.
This Act may be cited as the 'Dialyzor Quality Act of 2018'.
SEC. 2. COVERAGE OF MORE FREQUENT HEMODIALYSIS TREATMENTS.
'(15)(A)(i) Not later than the date that is 1 year after the date of enactment of this paragraph, the Secretary shall cause to have published in the Federal Register final regulations for equivalent per treatment prospective payment rates for more frequent hemodialysis furnished outside of self or home training (commonly known as the dialysis bundled payment rate); payment for more frequent hemodialysis furnished at home, and furnished in a facility.
'(ii) For the year beginning more than 12 months after the date described in clause (i), and for each subsequent year, the Secretary shall provide for an appropriate update to the per treatment prospective payment rates developed under clause (i).
'(II) data on expenditures for beneficiaries undergoing hemodialysis treatment 3 times per week with similar clinical and demographic characteristics.
'(C) Not later than 1 year after the date of enactment of this paragraph, the Secretary shall develop, in consultation with the renal community, a standard of care and quality standards for more frequent hemodialysis. The Secretary shall periodically review and update as necessary such standards.
'(ii) the improved quality of care and improved outcomes more frequent hemodialysis may bring to beneficiaries.
'(i) The term 'more frequent hemodialysis' means hemodialysis treatment sessions, or equivalent therapy requiring blood access, performed routinely more often than an every other day dialysis schedule.
'(ii) The term 'qualified individual' means an individual who, in the clinical judgment of the physician of the individual, is likely to achieve better clinical outcomes, quality of life outcomes, or both from more frequent hemodialysis.'.
(b) CONFORMING AMENDMENTS- (1) Section 1881(b)(8) of the Social Security Act (42 U.S.C. 1395rr(b)(8)) is amended by inserting 'and more frequent hemodialysis supplies and equipment' after 'home dialysis supplies and equipment'.
(2) Section 1881(b)(9) of such Act (42 U.S.C. 1395rr(b)(9)) is amended by inserting 'and more frequent hemodialysis support services' after 'self-care home dialysis support services'.
(c) EFFECTIVE DATE- The amendments made by this section shall take effect on the date of the enactment of this Act and shall apply with respect to items and services furnished on or after the date that is 1 year after such date of enactment.
Existing Electronic Medical Record systems (EMRs) can be improved by changing the way staff access the screen they need.
Currently EMRs speed users to a screen tailored to a procedure for a given patient with as few clicks as possible. After typing a few letters of a patient's last name, the EMRs user can select the screen of interest from a drop down list, a physician rounding will have their list of billable procedures, a technician will have theirs. This process should be slowed down a beat by putting the procedure links below information specific to the individual, information curated by the individual or on the individual's behalf.
EMRs will be tailored by/for an individual to tell medical staff what the individual in their role as patient would like them to know; what the individual in their role as a Medicare beneficiary would like them to know; and what the individual and their primary care physician(s) believe are important metrics.
I prefer Mrs. Jones not Sue or Susan and certainly not Suzie.
I want to visit 50 countries, I've gotten to 35.
I want to be there for my spouse, she is frail so I need to be well.
Links to the screens staff use to best do their work, will be right below information that staff can use to best provide care.
I'm going to be in New York CIty on Wednesday to give half of a talk: Pay for performance in ESRD; defining CQI Metrics focused on disease center performance and metrics focused on the patient experience. What are SF36 and NQF?
The 2017 Alison Norris Symposium: The Impact of Policy on Medical Care of Kidney Patients is free but you need to register. It runs from 3PM to 9PM this Wednesday (December 13, 2017) with a reception break from 6:30 to 7:30 and it isn't just me talking there's a whole lineup of great speakers. I'm very much looking forward to attending.
The Symposium honours the memory of Dr. Alison Norris whose interest in the psychosocial and ethical aspects of kidney care I share. My talk will be the view from the sharp end of the needle, about the value and limitations of patient reported outcomes and patient-centered care. As well my view of current legislation and trends.
The Symposium is taking place on what looks to be the Upper Upper East side, Fifth Avenue at 103rd Street. Come by, talk dialysis, say hi.
You are obviously proposing a radical change.
It is a radical change, a different radical change from the one previously proposed. Instead of a business relationship at the center of the chronic dialysis care model, self-centered care puts the individual at the center. To be a 'patient' is to be in a business relationship. Patient-centered care focuses on the interaction between a patient and the unit - not an individual and the unit, rather an 'average' patient and the unit. Unsurprisingly creating a system to serve the average patient does not produce the results we want no matter the intentions of everyone involved.
The latest attempt to achieve our desired results would be a radical change. It is on the table, already working its way through Congress. It has 98 cosponsors. It is not a good idea.
DPDA (the PATIENT Act) S.2065/H.R.4143 would in effect make one of the large dialysis organizations the Part A and Part B fiscal intermediary for Medicare dialyzors throughout a region. Dialyzors at every provider in a region would have one of the two large dialysis organizations as their healthcare command point. That is a radical change, It will take an Act of Congress to demonstrate this approach.
In order for a DPDA to be tried all sorts of state regulations and requirements have to be cast aside, superseded with the signature of the president. That's pretty radical. If DPDA works one of two giant for profit companies that have made billions of dollars providing dialysis to Americans will be paid additional billions for hitting their numbers. That also sounds radical.
I believe you are proposing to pay dialysis patients for "hitting their numbers." Politically, I think this would be an incredibly hard sell. U.S. taxpayers are already paying for a carve-out in the Medicare program that exists just for dialysis patients and costs approximately $80,000 per patient per year. Aren't wellness and avoiding complications enough of an incentive?
You asked about financial incentives, in a copernican self-centered dialysis system the incentives would be directed at the individual. Why would the taxpayer be willing to pay DaVita $2,000 if they are able to get that $80,000 down to $76,000 but would balk at paying patients to do the same thing. Here's a thought experiment: every Medicare dialyzor in Network 14 is assigned to the Copernicus14 Dialyzor Self-centered Care Demonstration. If the census in the demonstration achieve census-wide savings CMS agrees to share savings in excess of 2% to all beneficiaries.
Suddenly, the infection control seminar I voluntarily give down at the library might actually see attendance. And because it would be in my interest I might be more willing to drive an hour to give my seminar to a few other dialyzors (I don't actually give an infection seminar but I would if people attended). The units would still have their patient-centered metrics to achieve; now they would find an audience and messenger for their patient-centered education.
In the unit dialyzors engaged with the plan would have incentive to get others onboard but more than that they would have standing to monitor the unit. Handwashing policies would find advocates in the engaged. Engaged dialyzors would have an interest in improving everyone's care one individual at a time, starting with themselves.
An upside scenario comes to pass, Copernicus14 sees spending decline across the entire census by 5%. Each participant has $1,200 in SS tax paid into their account about the amount $10,000/year in wages would generate. The beneficiary would get the actuarial value of the tax, the taxpayer would get a very good deal indeed.
I believe expecting dialysis patients to manage their overall care would be overwhelming for the vast majority, especially new patients. It takes years to develop understanding and expertise in the complexities of the various therapies and in the self-interests of the industry players. If your system was implemented, I believe nearly all new patients would have to rely on an advocate to help them. Who would fill that role… and at what price/cost?
If the self-centered QIP rewarded all the unit's dialyzors for unit level achievement in addition to process rewards directed at the individual the incentive would be for dialyzors to work together. People wouldn't be managing their own care, there are still techs, nurses and doctors, care plans ... but each individual would have a room full of peers who have a more direct interest in seeing them succeed. If it doesn't work, if nothing comes of the effort, we are left where we are today.
… paying dialysis patients to be engaged and involved in their care would likely result in similar demands from millions of people with diabetes, heart disease/failure and other chronic conditions.
I should hope so. Patient-centered care is widely practiced The current idea is for DPDA to be the model for the future, for dialysis then for the rest of the chronic disease spectrum, working alongside/through patient-centered care. But as long as we are talking about changing the way dialysis is provided via an Act of Congress let's look at some options. I can make the case for what I am calling self-centered care. One could say it's paying people. I'd say motivating people to be engaged, to be a coach, and to be coached.
The large dialysis organizations gained access to the per beneficiary Part A and Part B cost data through the various ESRD Affordable Care Organization demonstrations that are ongoing through ordinary Medicare regulatory processes. This is the first time anyone has been able to see the complete cost data beneficiary-by-beneficiary. What have the LDO's data teams found that makes them so anxious to take responsibility for all beneficiary spending? One wonders. Give dialyzors the data and dangle a carrot, many people will be amazed at what we can do.
How is this Copernican system defined in terms of policies, metrics, and financial incentives?
From earth whether we believe we are at the center of the universe with the Sun and all else orbiting us ... or vise versa, it looks the same. To the casual observer there is no difference, either way the sun comes up in the east and sets in the west. However, there is an undeniable difference in mindset and if you are working to understand our solar system it is important to see the world's place as it is, this is equally true in the provision of dialysis. Planet dialysis is not at the center of the system, planet dialysis orbits the patient. The patient is the star.
To a casual observer walking into a dialysis unit, self-centered dialysis would be indistinguishable from patient-centered dialysis. Where the two systems distinguish themselves is in the metrics and financial incentives. Today's patient-centered dialysis puts the provider at the center of the universe, unit-wide results are judged against unit-wide expected outcomes. The financial incentives are directed at the provider. The patient's role is to be the input and the output. The patient-centered dialysis unit takes in uremic inputs and turns out slightly less uremic outputs. The CEO of one large dialysis provider said his approach would be the same if he was taking in hamburger and turning out tacos.
... a central command point for patients to access the coordinated health care services.
DPDA imagines planet dialysis at the center of the system with a galaxy of stars swirling around in orbit. The strategy behind the legislation is that dialysis organizations large enough to participate, those with capital reserves sufficient under Sec.1866F (b)(3) of the Act, will use their size to save money. With DPDA total spending becomes a driving metric, the patient is a business input to be managed.
In contrast a Copernican-like dialysis system, self-centered dialysis, puts the patient Medicare beneficiary at the center (we are not Medicare's patients). The responsibility for achieving metrics are the beneficiary's and the financial incentive is directed at the beneficiary. To see yourself at the center of your care is to understand that no one, no matter how benevolent, will care as much about your well being as you can and should care about yourself. There is no better way to align financial incentives, optimal care and self interest than to reward Medicare beneficiaries for their individual outcomes.
Thus, a self-centered dialysis QIP would allow Medicare beneficiaries to withhold their Part B premiums if they achieved, as an individual, the QIP blood and process goals. Instead of the shared savings imagined under DPDA accruing to the dialysis provider, self-centered dialysis would accrue shared savings to the Medicare beneficiary, perhaps in the form of payments to their Social Security account. If total spending is to become the driving metric in the provision of dialysis, let Medicare beneficiaries act as the responsible party. The stars are not orbiting planet dialysis; a system based on the belief that they are is bound to end badly.
With The Modality Mayhem Of Modern Dialysis Dr Agar runs through the reasons why it is so hard for any of us to answer the question: What is the best dialysis option? On internet discussion forums it is common to see a "plea for help from a new-to-dialysis questioner", asking What should I do? How should I dialyze?
If the answer is greater than 1, then dialyze as much as you are allowed, while advocating to be allowed more dialysis. If the answer is less than 1, then it makes sense to ask if you would get more from dialyzing a different way eg. at home, overnight, +/- Qd; questions of lifestyle and how you feel doing what you're doing come to the fore.
Unfortunately for many dialyzors in the US their number will be greater than 1 and keeping a schedule that never exceeds 43 hours between treatments (the Agar Standard) is not an immediate or mid term option. Thus, my advice if you're dialyzing incenter three times a week: push your center to offer longer duration treatments, push yourself to dialyze longer. And light a candle that someday a provider somewhere will offer every other day dialysis incenter and that center will be yours.
Richard Rettig's seminal bio-medical paper from 1991, Origins of the Medicare Kidney Disease Entitlement: The Social Security Amendments of 1972 … is compelling reading.
Rettig's 1972 report and many of his other reports, e.g. 1996 2001 2011, are online and he was the primary editor of the 1991 IOM report Kidney Failure and the Federal Government also available online.
Dr. Agar's telling of the history misses an import logic underpinning the creation of the 1972 ESRD entitlement. In 1972 Congress voted a "review/extension of Medicare and Medicaid" AND expanded Medicare to cover the disabled. For the first time people could qualify for Medicare coverage if they qualified for disability under Social Security - if they were unable to work and otherwise qualified. The concern was that people who needed to use dialysis, were Medicare qualified, and wanted Medicare coverage would leave the workforce to file for (and receive) disability. Therefore, rather than say ESRD is the only disease that lets you use Medicare, it is more accurate to say that ESRD is the only disease that lets you use Medicare and keep your job.
The ESRD entitlement does not give people Medicare coverage for dialysis, being disabled gives people Medicare coverage for dialysis. The ESRD entitlement gives people who are covered under Medicare the opportunity to keep working. In 1972 the fear was that given the new disability entitlement dialysis patients would quit their jobs to qualify. The ESRD exception meant people could have Medicare and keep their jobs. This was the logic that calmed republican members of the House Ways and Means committee, though it is fun to imagine doe eyed fiscal conservatives dazzled into acquiescence by Scribner's silky smooth cost estimates.
The estimates were, in hindsight, wildly short of the true mark for all three: incidence, prevalence and cost.
Scribner wasn't predicting future incidence, prevalence; his initial estimates were off but not wildly. As to cost, was he wrong? $17,000 incenter cost in 1974 would be about $90,000 today, twice what Medicare actually spends for a year of dialysis per beneficiary. Agar does not say what he would advise Scribner et al. to do differently. Knowing what he knows now what message from the future would he have for his colleagues if he were able to travel back to 1972? Was there a path that led to a brighter future where home modalities thrive ungazumped??
Maybe? I've seen enough movies to know that a frequent outcome of time travel is something ironic and often tragic, but I'd tell Scribner, "it is too soon for Medicare to pick winners and losers among therapies not well understood. If Medicare pays more for incenter they'll promote the rise of incenter for profit dialysis. Scrib, can I call you Scrib?, when they ask you for a cost estimate (and they will ask you!) just keep it simple, $17,000 to $20,000 per patient per year but we are hopeful less expensive approaches will prove out; that we will see as dialysis use increases per beneficiary per year cost decline and quality improve year after year.
My asking the questions: could 3x3 dialysis 'work'? is HD a shield?, is not a signal that I have changed my mind about any of my previous positions (though I might have since I don't have a running list). Rather these questions reflect a different understanding of the challenge. Primarily a heightened awareness of the tyranny of numbers.
We have only BEGUN the fight for the hearts and minds of new dialyzors. Of COURSE they are "choosing" standard in-center HD at a rate of 90%. They are SCARED when they need to make a modality choice, and we don't help them deal with their fear.
And, their nephrologists (just 6% of whom would choose standard in-center HD for themselves) can bill for 20 patients in an hour x 3 or 4 shifts per day x two schedules (MWF/TRS) per week in-center, and are lucky to fit in 3-4 patients in an hour at home. They make MUCH more money on in-center HD than on home treatments. So, patients who ASK for home treatments are reasonably likely to get them--but the rest end up in-center.
Both of these issues are fixable, and while you may be giving up the battle to get more folks home on better dialysis, I am not. Yes, we need to optimize in-center HD. Better dialyzers and more attention to ultrafiltration rates will help that. But, meanwhile, Transitional Care units are starting up, more attention is being devoted not just to education but to assisting the emotional adjustment of new patients, and home HD will continue to grow, with or without the MACs' help.
I agree, except the part about "giving up the battle to get more folks home on better dialysis". I'm saying even if the system could support 100,000 home dialyzors, which it can't for the foreseeable future, that leaves 400,000 individuals incenter. What about them? We need to talk about research that will benefit all dialyzors, not just me, and others willing to dialyze at home.
Consider a unit that introduces hemodiafiltration. Some patients will react by thinking: it is great that my dialysis prescription leaves me feeling better! Other patients will react by thinking: it is great that I can keep how I feel the same and decrease my dialysis prescription! The later is not wrong or ill informed for wanting less dialysis they're allowed to make this choice.
How I handle my dialysis is in my experience a superior option, of available options; my wish is that all dialyzors feel the same way about their choice. If we can find tools to assist dialysis, tools that allow people to dialyze the same and feel better, then we will have found tools to make all dialyzors feel better whether they dialyze a lot or a little.
Perhaps what I should have said is that we need new out of clinic therapies. Home treatments that are not dialysis.
Can we not imagine a way to remove solutes other than by dialysis?
As Dori says I do know that the only way three hours of dialysis three days a week could work for me (not that I am considering it) is if I had working kidneys. It is true. Actually I'd say, if I had kidneys that worked a little (enough) maybe I could get by. On Facebook Dan reports that his short daily schedule "barely works for him". I tried short daily, I'm sympathetic. If Dan had a kidney that worked a little, he'd find it easier. With a kidney that works a little, whatever dose of dialysis you are using, you will feel better than you would without the assist. From the point of view of the dialysis treatment the weak kidney is a tool, a tool that improves the overall renal replacement outcome.
Imagine a case study of twin dialyzors, the same in every respect but one has some residual function, twin A, and one does not twin B. (one used the contrast, one said no). What solute or solutes are in the body of twin B that are not in the body of twin A? They both are getting the same dialysis dose, but generally twin A feels better than twin B.
Can we not imagine a way to remove solutes other than by dialysis? Not to restore people back to perfect renal health but to get twin B feeling as well as twin A. I'm all for implantable artificial kidneys with outcomes rivalling a perfect transplant but at the same time we should advocate for incremental progress. One solute at a time, if that is what it takes.
We need ways to remove solutes outside of the dialysis clinic so that what happens in the clinic leaves people feeling better. But first we'd need to know what solutes we need to remove.
I admit that I was a little excited when I checked in with renalWEB this morning. There was late breaking news from American Society of Nephrology's Kidney Week 2017 Annual Meeting last week: Seven Days a Week Dialysis Service Positively Impacts Patient Compliance, Hospitalization and Survival. I thought finally a unit tried EOD schedules! but no, it is an incenter short daily program. This is good, don't get me wrong but I was disappointed the unit was not offering an EOD option alongside their daily program.
It is time to extend this flexibility to all dialyzors, it is time to routinely offer incenter dialyzors a full menu of treatment schedules.
I remain hopeful that someday, someone, somewhere in this world, a unit will try EOD treatments and when they do the benefits of will accrue to the provider, payor and patient (Part One); (Part Two); (Part Three); (Part Four); (Part Five); (Part Six).
I'm dialyzing for the second time on my trip through the Grand Canyon, this was the most challenging treatment. The video starts with the question what did you think about today's treatment?
In the middle, I'm talking about not wanting to leave my name in the canyon, or on the river, because we came to the realization that the only time you get something named for you is if it kills you ... thankfully there isn't a NxStage rapids or the Peckham cliffs.
In the end I'm thinking about how rafting white water is analogous to dialyzing. For most people dialysis isn't a float trip. Most people using dialysis see more than their share of rapids, and just like rafting to get through dialysis rapids you need your own momentum. You shouldn't just stick out your arm and turn your head, any more than you should sit on your paddle and float. You have to engage. In both instances you have to identify challenges, to avoid them or when that isn't an option you need to go right at them with your own momentum. You need to be going faster than the river, that's how you keep the control that is available.
Dialyzing at home over night, while I sleep continues to work well for me. Frequent nocturnal dialysis is by far the least burdensome treatment I've had during my entire 25 years with CKD stage 5. I could not do my job if I was using any other form of hemodialysis. I spend about four or five hours a week futzing with my treatment, four or five hours of awake time. It works great for me and frustrates, angers me that access to this categorically less burdensome treatment is limited in this country by zip code and paternalistic habits of care.
The sad news is I had to say goodbye to Cairny, my nearly thirteen-year-old Australian Shepherd last August after about 10 months of diminishing health. He followed Brainy, the Aussie that came into my life 5 months before my transplant in 1988. The fact is I have to have an Aussie and am now living with Banjo a ten month old black tri Aussie (BTW, Banjo is the type of fabric we use in tradeshows to delineate booths). Cairny was a swimmer, we went swimming many times together, and as of Sunday Banjo is a swimmer, so I am looking forward to a wet summer.
Speaking of getting wet - I'm rafting the Colorado RIver through 220 miles of the Grand Canyon from July 3rd through July 10th. Eight days, seven nights, four dialysis treatments. I'll start posting updates and ultimately trip reports on DSEN. The Grand Canyon, rafting the Grand Canyon, is something I would point to as a limitation of dialysis - I can go to Europe, but rafting the Grand Canyon is out. I had a chance to raft the Canyon the summer I was 15 but turned it down for stupid kid reasons. I've always taken that as a life lesson, take opportunities when they come because another chance is never promised.
Never promised but occasionally you do get another chance.
At the risk of becoming The Bruce Dikinson of the dialysis industry, when I read the JASN abstract that connects skipping dialysis with URRs below 65%, and thus a 1% payment withhold under the QIP, I think the only prescription is more cowbell! dialysis! Offering Every Other Day (EOD) schedules is the best response to control the cost of skipping.
The JASN paper only addresses the costs associated with being subject to a 1% withhold under the QIP, this understates the cost to the unit of skipping.
Think of a person who comes every treatment, who dialyzes 156 times a year, who we'll call G ... compared to someone who tends to skip twice a month and at the end of the year has dialyzed 130 times, who we'll call D.
First, one reason a person may skip regularly is that they don't feel very well when they do dialyze three times a week; if you're going to feel unwell if you do or you do not go to dialysis, you'll be more likely to not go. EOD schedules, when followed, would increase the person's chance to feel well, thus their ability and willingness to accommodate regular dialysis. But we're talking money, skipping and costs.
On the cost front, consider G's financial impact. Each dialysis payment under the expanded bundle is made up of fractional payments. Lab tests are in the bundle; each one of G's 156 reimbursements include some amount intended to cover lab tests. If G dialyzes 13 times in the month it means that the unit received 13 fractional payments intended to cover the cost of labs.
In addition with each payment the center received fractional payments to cover other monthly services and fractional payments for services that are delivered quarterly or yearly. All sorts of services required by the Conditions for Coverage are paid for a little at a time out of each individual, treatment, reimbursement e.g. the cost of care planning, iron, social worker support, PTH tests, Hepatitis tests, nutritionist support are all paid for a little at a time, by each treatment even though they don't necessarily happen each treatment.
Now consider D's financial impact. Labs still need to be done each month but at the end of the month there are only 11 fractional payments available to pay the cost of running the tests. D, just through skipping, generates 16% less revenue to pay for services delivered at frequencies less than each treatment.
The biggest financial effect may be D's EPO profile before and after skipping. In general let's assume D will need the same yearly dose of EPO whether dialyzing 156 times a year or 130, D will need 624,000 units of EPO (likely D would need a higher yearly dose due to skipping). If D runs 156 times the EPO dose will be 4,000 units per treatment. If D runs 130 times the EPO dose will need to be 4,800 units per treatment. D's skipping makes each treatment less lucrative, over and above any QIP withhold.
EOD schedules fix the financial side of this problem. Skipping in and of itself is a clinical problem, and as the JASN authors note there are as many reasons for skipping as the mind can imagine. But skipping shouldn't mean not having access to dialysis and units shouldn't be trapped into a needless financial drain. I don't think D is thinking: I only need to dialyze 11 times this month, more likely, about twice a month, D has a sense that: I need a break.
With an EOD schedule D would receive the 13/month medical minimum number of treatments - enough dialysis to avoid expensive hospitalizations and keep URRs above 65%; the unit would have received the number of payments anticipated by the bundle to pay for formerly separately billable services; and D would have had two breaks during the monthly grind. Win. Win. Win.
D should be given an EOD schedule and expected to call the unit as soon as the intention to skip is known.
Every Other Day (EOD) incenter dialysis schedules can be done (Part I); EOD schedules would improve clinical outcomes and support patient choice (Part II); EOD schedules are implicitly supported by MAC/FIs (Part III); EOD schedules would improve the clinic's finances and may lower overall Medicare costs per person, per year (Part IV); EOD schedules would increase the clinic's value (Part V). And, EOD schedules are a sensible clinical and financial response to patients who routinely skip treatments.
This is Part Five, the last in a five part DSEN series making the case that Every Other Day (EOD) incenter dialysis schedules can be done (Part One); EOD schedules would improve clinical outcomes and support patient choice (Part Two); EOD schedules are implicitly supported by MAC/FIs (Part Three); EOD schedules would improve the clinic's finances and [edit; equivocation] may lower overall Medicare costs  per person, per year (Part Four); EOD schedules would increase the clinic's value (Part Five).
Let me say from the outset that I don't usually spend a lot of time on dialysis industry equity prices and the concerns of shareholders. I own no stock related to the provision of dialysis. However, as Peter's comment today nicely illustrated, the owners of the capital need to be part of the discussion. I think the case that the seventh treatment would be financially lucrative, is strong. But that is not quite the same thing as value. Today's shareholder is most interested in value.
Would EOD schedules increase the clinic's value? Certainly. Shareholders should be EOD schedules' biggest proponents.
It is easy to think that value to a shareholder relies entirely on net income and ultimately it is true an equity share price has to correlate to net income. But it is net income as it is expected for that industry, for that business, for that business at this point in its life cycle. Dialysis as an industry is at the mature stage of its business life cycle. Most of the dialysis in the United States is provided by two large dialysis organizations that are for profit companies with equity shares available to the public and are generally understood to be at the mature stage of their business life cycles.
Being at the mature stage leads investors to have expectations of what it means to serve X number of patients or operate X number of facilities. This is why changes in insurance reimbursement are such a big deal to the dialysis industry - whether it is regular inflation adjustments to Medicare's payment (+), or two percent cuts to per treatment funding (-), or the new role of the exchanges (+/-?) it's a big deal because it changes the value of the companies. If average reimbursement goes down, for whatever reason, 100,000 patients are not going to be worth what 100,000 patients were worth the day before. In the world of equity traders what a patient is worth ultimately determines what a dialysis provider is worth.
The good news is we're worth quite a bit to these equity traders, over $85,000 a piece if recent sales are our guide (here, here). We're being sold not as people but as dialyzors. Buying/valuing an established dialysis provider would be like buying/valuing an airline. Sure you pay something for the planes but mostly you're paying for the right to the routes and the airline's frequent fliers. The units are the routes and dialyzors are the frequent fliers. To a shareholder the fact that dialyzors, unlike most frequent fliers, are largely captive of their proximate service provider is a feature not a bug. Providing dialysis and being in position to provide dialysis in the future, has equity value.
EOD schedules increase that value. If patients are worth $85,000 dialyzing six days every two weeks, they're worth more dialyzing seven. EOD schedules increase the value of the provider because they increase the expected value of serving a patient. EOD schedules advance shareholder interests.
Providing every other day incenter dialysis schedules would increase the value of the provider.
Do EOD schedules offer financial benefits to Payers and Providers?
This is Part Four of the unheralded five part DSEN series making the case that Every Other Day (EOD) incenter dialysis schedules can be done (Part One); EOD schedules would improve clinical outcomes and support patient choice (Part Two); EOD schedules are implicitly supported by MAC/FIs (Part Three); EOD schedules would improve the clinic's finances and [edit; equivocation] may lower overall Medicare costs  per person, per year (Part Four); EOD schedules would increase the clinic's value (Part Five).
At their simplest clinic finances are the average reimbursement per treatment vs the average cost per treatment. EOD schedules manifest as one extra treatment every two weeks and compared to the conventional treatments, that treatment would have a higher average per treatment reimbursement and a lower average per treatment cost.
The seventh treatment, the extra treatment of an EOD schedule, would have higher average reimbursement per patient because use of EOD schedules would skew towards people who drive themselves to dialysis, and as a group, people who drive themselves to dialysis have better insurance than people who rely on funded transportation.
The seventh treatment would also have lower non-labor costs. Services such as EPO, iron and labs are fully funded after 6 treatments, meaning in effect the seventh treatment would carry a ~$70 premium. This gain would have to be weighed against the wage premium and possible tenant costs associated with opening on Sunday, but the higher average reimbursement and lower non-labor costs suggests EOD schedules would be viable with relatively few patients.
Beyond the straight revenue/cost analysis EOD schedules would be a financial plus if it keeps patients out of the hospital. Dialysis units pay a price when their patients are hospitalized, and they will benefit if EOD schedules keep their patients in their chairs, dialyzing. Thus, it is an important, fundamental question - will EOD schedules keep patients out of the hospital?
The answer is yes. Would the decrease in hospitalization cover the added cost of EOD schedules? I think so but, on reflection (hence the edits to the position statement) I can't make a very solid case. It is not a simple question to answer. The added cost for Medicare of EOD schedules would be about $5,000 (80% allowed $ x 26) per patient per year and there looks to be $5,000 to be saved in hospitalization cost. On average in 2008 (most recent data year) people who use hemodialysis spent 14.5 days in the hospital, at a cost to Medicare north of $30,000.
However, the people who choose EOD schedules might not have average hospitalization profiles, if they are healthier than average it means there is less hospitalization costs to save. And if EOD schedules improve survival, if EOD schedules extend people's lives, that will increase total Medicare spending.
And, it does give one pause that incenter EOD schedules are provided no where on Earth. All routine incenter schedules include the dialysis weekend, no matter if the dialysis is being provided through a for profit system or a centrally planned, state owned hospital, . You would think that if EOD schedules saved their cost that systems that fully paid for both the dialysis and the hospitalization would offer EOD schedules. They don't, so maybe EOD schedules wouldn't lower total spending (though I am not convinced, groupthink would be an alternative explanation), but even if EOD schedules don't lower total Medicare healthcare spending they should still be offered.
The dialysis weekend represents a cost shift of sorts. Not getting regular dialysis is risky but patients are instructed in how to decrease the risks through strict dietary control. The added dietary restrictions are a cost. The dialysis weekend increases risk and increases the cost of care to the patient. That doesn't sound like a system that is up to our standards.
EOD schedules would improve the clinic's finances. EOD schedules lower overall Medicare costs EOD schedules may lower the overall Medicare costs per person, per year.
Would Medicare routinely reimburse EOD dialysis schedules?
This is Part Three of a five part DSEN series making the case that incenter Every Other Day (EOD) dialysis schedules can be done (Part One); EOD schedules would improve clinical outcomes and support patient choice (Part Two); EOD schedules are implicitly supported by MAC/FIs (Part Three); EOD schedules would improve the clinic's finances and [edit; equivocation] may lower overall Medicare costs  per person, per year (Part Four); EOD schedules would increase the clinic's value (Part Five).
The question has to be asked - would EOD schedules receive routine reimbursement from Medicare, in the same way that conventional schedules receive routine reimbursement? My review of the documents online leaves me to conclude that Medicare support of EOD schedules is implied though not plainly expressed. It is possible that, short of a National Coverage Decision (that anyone can initiate) it may be necessary to fight for routine EOD dialysis reimbursement but that is a fight worth having and on this ground it is a fight dialysis unit administrators can win.
Medicare Administrative Contractors (MACs) are entities, created by 2003 legislation, that are contracted to pay claims on behalf of Medicare. The country is divided into 15 regions and each region has a MAC (I think there will eventually be 5 MACs, possibly 10 but it is confusing; current list here (PDF LINK)). When a dialysis unit submits a claim, that claim is submitted to their MAC, who then rejects, or authorizes and pays, the claim.
Hemodialysis and peritoneal dialysis are covered at the frequencies shown below under the composite rate. Additional composite rate payments may be made when they are medically justified.
MACs are guided by the Medicare Benefit Policy Manual when making claim decisions. According to the claims manual additional dialysis treatments can be reimbursed when they are medically justified but if additional hemodialysis treatments are provided it is up to the MAC whether medical justification is required.
Not experimental or investigational (with exception).
HEMODIALYSIS sessions which exceed the frequency of three sessions per week must be medically reasonable and necessary.
Hemodialysis and peritoneal dialysis performed or billed more than three times per week is reasonable and medically necessary for hyperkalemia, pregnancy, fluid overload, acute pericarditis, congestive heart failure, pulmonary edema or severe catabolic state when these conditions are refractory to dialysis three times per week.
The Trailblazer LCD doesn't preclude payment under other circumstances, but it does suggest that payment for four or more treatments in a week would not be routinely granted. But what about three and half treatments a week?
An EOD schedule (3.5 treatments per week) uniquely meets the directive that duration and frequency of service be "One that meets, but does not exceed, the patient's medical need."
all-cause mortality (22.1 vs. 18.0 deaths per 100 person-years, P<0.001), mortality from cardiac causes (10.2 vs. 7.5, P<0.001), infection-related mortality (2.5 vs. 2.1, P=0.007), mortality from cardiac arrest (1.3 vs. 1.0, P=0.004), mortality from myocardial infarction (6.3 vs. 4.4, P<0.001), and admissions for myocardial infarction (6.3 vs. 3.9, P<0.001), congestive heart failure (29.9 vs. 16.9, P<0.001), stroke (4.7 vs. 3.1, P<0.001), dysrhythmia (20.9 vs. 11.0, P<0.001), and any cardiovascular event (44.2 vs. 19.7, P<0.001).
In order to meet a patient's need, in order to have 18.0 deaths per 100 person-years, instead of 22.1, patients have to adhere to an EOD schedule. Dialysis on an EOD schedule is reasonable and necessary.
EOD schedules are implicitly supported by MAC/FIs.
This is Part Two of a five part DSEN series making the case that Every Other Day (EOD) incenter dialysis schedules can be done (Part One); EOD schedules would improve clinical outcomes and support patient choice (Part Two); EOD schedules are implicitly supported by MAC/FIs (Part Three) EOD schedules would improve the clinic's finances and [edit; equivocation] may lower overall Medicare costs  per person, per year (Part Four); EOD schedules would increase the clinic's value (Part Five).
I haven't seen, compared to a conventional schedule, the clinical benefits of an EOD schedule disputed. That the dialysis weekend is risky is well known. Most recently a NEJM paper reviewed the evidence but the data has been consistent since the 1960s. Routinely avoiding the weekend should routinely lead to better clinical outcomes.
The tougher questions to answer are concerns that patients would not want to switch from conventional three day a week schedules to EOD schedules, that patients prefer three day a week schedules.
Unless there is a choice it can not be said that there is a preference. For patients who want to dialyze incenter there is little access to higher frequency dialysis. Incenter patients do not have agency to decide their dialysis frequency. I believe that if there was a choice and the risks that are inherent in the dialysis weekend were well understood a significant number of patients would choose the safer schedule.
Some patients due to transportation issues would not be able to use an EOD schedule. Some patients would prefer the set weekly schedule allowed by conventional three day a week dialysis. Some patients seeing EOD schedules as requiring more from them would feel like they are doing all they can and they just aren't able, at this time, to do any more. This is all to be expected and accommodated.
However, some number of patients would want to use the safer schedule and would choose to dialyze EOD. How many is not a number I can give. Each patient would have to make their own personal cost benefit analysis but I think there is reason to believe that most patients would reckon EOD schedules to be a good value.
We're not use to thinking in terms of weekly dose of dialysis, let alone the biweekly dose of dialysis, but I think we should. Talking about treatment duration alone obscures dangerous anomalies like the dialysis weekend. One way to quantify the impact of the weekly dose of dialysis is the HemoDialysis Product (HDP). The HDP assigns an impact value to various weekly dialysis schedules (D&T just republished the Scribner classic) using a simple formula: HDP = (hrs/dialysis session) x (sessions/wk)2.
My experience supports using HDP as a way to understand the impact of various schedules; how various schedule would make me feel as compared to other schedule options. In order to decide if I would use an EOD schedule I would want to weigh the benefits against the cost. Would I feel better, would the burden of CKD5 be less vs. spending more time dialyzing and taking into account the net effect of additional time getting to and from the clinic and the time spent recovering from the dialysis treatment. The costs are easier to reckon then the benefits, the HDP provides a way to quantify the expected benefits.
A conventional three day a week, four hours per treatment schedule has a HDP=36; keeping treatment length the same but dialyzing once more every two weeks, i.e. going to an EOD schedule, brings the HDP up to 49. Thus, increasing the amount of time dialyzing by 16.6% - from 6 days every two weeks to seven days evey two weeks - will increase the impact of therapy by over 36% - from 36 to 49.
Another way to say it is that going from 12 to 14 hours of treatment per week, in effect, in this way, through frequency, increases the HDP 13 points. If instead you increased your weekly time to 14 hours while keeping frequency the same, i.e. doing four hour forty minute runs three times a week, your HDP would be 41.94, a six point gain. Frequency gives more dialysis 'bang' for a dialyzor's 'buck', paid in time.
The EOD schedule is the better value. There is every reason to believe that if EOD schedules were offered, EOD schedules would be a popular choice.
Think of the very good financial advise to pay your mortgage every two weeks instead of every month. If you pay every month you will make the 12 payments and four times during the year you get an extra week of income between payments. Having an extra paycheck between mortgage payments is pretty great. But if you pay every two weeks you end up taking years off of your mortgage, saving lots of money and you don't really notice that you made a 13th monthly payment during the year. An EOD schedule would be like agreeing to pay your mortgage every two weeks instead of every month. It's the smart move.
Offering EOD schedules improves clinical outcomes. Offering EOD schedules supports patient choice.
My contribution to the excellent discussion taking place on The Kidney Doctor (spring boarding off the Atlantic article) puts forward incenter every other day dialysis schedules as one of the solutions needed to improve the clinical outcomes of those who use dialysis. I am an advocate for incenter every other day dialysis (e.g. the petition, here, here), I have not heard anyone dispute that this would be better clinically but some might question this, the push back I have heard has been that it is impractical. Not that it shouldn't be done, but that it can't be done. Or it can only be done at too high a financial cost.
I say that Every Other Day (EOD) incenter dialysis schedules can be done (Part One); EOD schedules would improve clinical outcomes and support patient choice (Part Two); EOD schedules are implicitly supported by MAC/FIs (Part Three); EOD schedules would improve the clinic's finances and [edit; equivocation] may lower overall Medicare costs  per person, per year (Part Four); EOD schedules would increase the clinic's value (Part Five).
The most specific concern that I have read is that you couldn't do EOD dialysis schedules for some patients but not others. "You can't be a little bit pregnant" the skeptics remind, contending that a unit would have to go entirely to an EOD schedule to offer anyone an EOD schedule. "They'd have to be 100% in or 100% out", "What clinic can accommodate its entire pt population for an additional treatment day?".
I would not advocate switching entire incenter populations over to EOD schedules but I think all patients should be offered EOD schedules. Transportation to the unit, specifically funded transportation, is an issue outside the control of units and represents a real barrier to EOD schedule access. I don't see EOD schedules being used by a majority of patients but I do believe it would be a popular choice if it was widely available.
What follows is an example of how a unit could operate with some patients using an EOD schedule, while other patients, the majority of patients continue to use a conventional three day a week schedule.
Consider a 24 station unit - operating six shifts Monday through Saturday at 80% capacity, a unit with 115 patients dialyzing 3x/week on average for 3.5 hours.
The unit would have to have in mind the minimum number of patients they would need to have dialyzing on Sunday to open the unit (the unit conventionally runs Mon to Sat). And then double that number to find how many patients the unit would need to start EOD schedules. It's a question of staffing.
Staffing a Sunday shift would be more costly than an average conventional shift but the treatments provided would carry more reimbursement. There would be different staffing requirements for different units, depending on case mix among other factors. For ours the number is 12, the unit would need 12 patients to make opening the unit on Sunday viable. Thus, the unit needs 24 patients to want EOD schedules for it to make sense to start their EOD program.
36 patients have agreed to switch to EOD schedules (there will need to be another post on how it might come to pass that a third of a unit's census would agree to switch but it would start with buy in from the patient's MCP physicians).
The first step to make this work is to divide the EODers into two groups of 18 (a number well over the 12 patient threshold). Instead of calling them MWF and TTS we'll call them Group 1 (G1) and Group 2 (G2). At this unit the interest in EOD skewed to the evening shift.
To accommodate the EODer's shift preferences the unit manager has to have 8 stations on the evening shift (16 wanted EOD) and 5 stations on both the morning and mid day shifts (10 patients on each wanted EOD schedules). As the EOD census grows or contracts G1 and G2 have to stay in balance, just as the shifts generally have to remain in balance. However, unlike MWF & TTS, G1 & G2 are indistinguishable from the dialyzor's point of view so switching between the groups should not represent a problem but it will mean that there will be times when patients have to shift from G1 to G2 or vise versa - as long as the number of patients on G1 and G2 is greater than 24 (12+12) the program remains viable at this unit.
It's Monday and G1's turn to dialyze. The patients get themselves to treatment and arrive at their appointed times, receiving their treatments normally. If they use ESAs they receive their dose. This continues through the day. From an operational stand point it should look like any other Monday even as this tectonic shift in the provision of dialysis is taking place.
G2 comes in for their dialysis. As with G1 this looks like any other Tuesday from an operational stand point. Unless you looked at their charts you wouldn't be able to tell G2 patients from the conventional TTS patients. But as a group they do skew towards the units younger and healthier patients. Many of the unit's older and sicker patients rely on funded transportation to get to and from dialysis and it has not yet been worked out how to make funded transportation compatible with EOD schedules. This reality does mean that as a group the EODers are younger, healthier and have better insurance than the unit's patients generally.
The unit would continue to operate per usual, without any unique staffing requirements. In gathering supplies and preparing stations, staff would know they were getting ready for Wednesday and G1 or Thursday and G2. If it was time for labs they'd be drawn, iron would be given, visits with doctors and staff, nutritionists and social workers would take place normally.
On Sunday G1 would come in for dialysis. From the patient's point of view Sundays would be different. On every other day of the week you'd come in at your normal time but if dialysis fell on a Sunday you'd come in, most likely, at a different time. Having a special Sunday time for dialysis, different from dialysis on conventional days, is what allows EOD schedules to embed in a unit with a majority of patients using conventional schedules.
It might be that on Sunday G1 and G2's dialysis is always during a window from 8AM to 2PM or it could be that G1's Sunday is from 10AM to 6PM and G2's is from 8AM to 2PM. The options would need to be evaluated based on patient and staff preferences and availability but ultimately most patients would need to accommodate a time outside their conventional time. Until the EOD census grows it will be necessary to operate the unit for just part of the day on Sunday. Additionally by operating the unit for only six or eight hours the unit would still be available for maintenance tasks typically done during off hours.
It's 10AM, G1 arrives in waves of four, 20 minutes apart. The four techs and one nurse get 18 patients dialyzing by noon. At the height of operation the unit operates 18 stations at once with a slightly higher staff/patient ratio then their conventional standard, since no medications, labs or ongoing education is taking place and there are no deliveries and few phone calls. The patients have event free treatments, they are generally healthier than the average unit patient and they have not had two days off. Note that no formerly separately billable services are provided on Sunday but payment is the same, resulting in the ~$70 included in the bundle for formerly separately billable services to be available for increased staffing costs.
G2 comes in for dialysis. From an operational perspective it should look the same, setting up treatments based on a patient's prescription. Staff would know to set up for Monday and G2. The only difference I would expect to be apparent is that G2 would not show the effects of taking two days off while the conventional Monday patients would continue to show the symptoms associated with the break in their routine renal replacement.
Incenter every other day dialysis can be done along side conventional dialysis schedules.
Thank you for the opportunity to comment on the proposed changes to the End-Stage Renal Disease Quality Incentive Program for PY 2013 and PY 2014 (QIP). My name is Bill Peckham. I have been a Medicare beneficiary since 1988 and have used dialysis since 1990. My comment primarily concerns the proposal concerning anemia, so I note that I have used ESA therapy in the past though for the last ten or so years with diminished frequency and as of today it has been nearly four years since my last dose; today I have a normal red blood cell count and thus do not, at this time, use ESA therapy.
I work as a sign maker, through the union, in the tradeshow and hospitality industry. I volunteer in various ways to promote the optimal health, quality of life and independence of people who use dialysis. I volunteer both with my provider, Northwest Kidney Centers, where I am immediate past trustee board chair and continue to serve in many ways, locally with the Kidney Research Institute, on the KRI Council, and nationally on the oversight committee of a federally sponsored comparative effectiveness research project, with DOPPS, on their steering committee and I volunteered to serve on the recent C-TEP looking for fluid management CPMs last year. Through my blog, Dialysis from the Sharp End of the Needle and participation in the CKD online community I've made many connections with people involved with the provision of dialysis, on both ends of the needle, and have had many discussions, over many years, about the details of Medicare reimbursement policy for those with severe kidney disease. The reimbursement details of CMS's ESRD program is my hobby; one I take seriously.
The dialysis community is still digesting the changes that have come with the bundle. The data I have seen through DOPPS and the reports I have heard through email and online communities, is that ESA use has declined since the final rule was announced a year ago. And that this has resulted in generally lower hemoglobins, which the effected dialyzors report, limits their energy and thus diminishes their quality of life.
Given this developing trend it is a particularly risky time to make the changes proposed in CMS-1577-P. Specifically, the proposal to eliminate the performance measure (CPM) "percentage of patients at a facility whose hemoglobin (Hgb) levels were less than 10 grams per deciliter (Hgb=10)" will magnify this trend to the detriment of your beneficiary's quality of life.
For patients with CKD on dialysis:Initiate ESA treatment when the hemoglobin level is less than 10 g/dL.If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of ESA.
This guidance suggests that a threshold of 10 g/dL is appropriate and complies with MIPPA's language that "measures on anemia management that reflect the labeling approved by the Food and Drug Administration for such management".
I propose that CMS continue the QIP's support of the FDA label's treatment threshold of Hgb=10 for payment year 2013 and 2014.
However, to improve the QIP and allow for care that is tailored for each beneficiary the QIP should move away from both the Hgb=10 and the Hgb=12 CPMs, to an anemia CPM that reinforces best practices and gives your beneficiaries a voice in their anemia management.
I propose that CMS institute a new QIP CPM: "percentage of patients at a facility whose hemoglobin grams per deciliter levels were more or less than ten percent of the Monthly Capitated Payment (MCP) Physician's target hemoglobin for that beneficiary" (%+/-Hgb Target).
In this year's final QIP final rule, CMS should propose using 2012 outcomes of a %+/-Hgb Target CPM as a benchmark to implement this new CPM in 2013 effecting payment in 2015.
I believe this makes sense because CMS is paying the MCP Physician to manage their beneficiary's renal replacement therapy, including anemia management. Thus it is appropriate that the QIP motivate units to put the MCP Physician's clinical judgment into practice. The NQF did not evaluate anemia CPMs based on the MCP physician prescription but I believe the Secretary has the discretion to take this approach under the exception clause of MIPPA Sec 153(c)(2)(A)(i).
I like this approach because the beneficiary can be included in the discussion as to where to set their personal Hgb target allowing the MCP physician to take their patient's view on the trade offs between a Hgb=11 vs a Hgb=9 into consideration when setting an individualized goal. Basing the goal on the MCP physician's judgment allows individualization in the framework of existing rules. Requiring MCP physicians to set and monitor the target should not be a burden since it is very nearly what is required today. This could be implemented by 2012.
One concern will be how to collect the information, how to report the MCP Physician's Hgb target. I suggest including the target with the reporting requirement to note ESA Route of Administration. Starting this January providers will be required to include the modifiers JA (intravenous administration) or JB (subcutaneous administration) indicating the route of administration on all ESRD claims with dates of service on or after January 1, 2012. Along with the route of administration, units should also be required to report beneficiary's MCP Physician's Hgb target. From there it would be a simple math equation to determine the unit's performance.
This approach to the anemia question would help to reinforce the role of the MCP physician as the medical professional in charge of the individual treatment details of each of your beneficiaries who use dialysis. The dialysis unit is being paid to implement a care plan that they jointly develop with the patient and the doctor, the proposed CPM would reinforce these separate roles.
Taking this approach forward the MCP physician's prescription could form the benchmark for other CPMs from the dialysis unit to the hospital. Meaningful CPMs related to bone health and Kt/v are very difficult to develop if they are meant to apply to every person using dialysis. I think a better approach would be CPMs based on the MCP physician's prescription for each beneficiary. The beneficiary's personal calcium, PTH, Kt/v and phosphorus targets would make useful CPMs. By showing confidence in the judgment of the doctors you employ to manage our care the QIP can implement CPMs that have much more meaning to the lives of your beneficiaries.
It may be that this time I veered too far to the quixotic and my comment doesn't fully meet my goal to offer thoughtful and actionable feedback. My focus these days is more on work, less on hobbies; it's hard to stay up to speed.
The Centers for Medicare and Medicaid Services (CMS) has a public comment period open right now for you to comment on proposed changes to CMS's ESRD Quality Incentive Program (QIP) that was mandated by Section 153c of H.R. 6331: Medicare Improvements for Patients and Providers Act of 2008 (MIPPA).
The most important proposed change from last year's QIP rule (PDF link) is the elimination of the Clinical Performance Measure (CPM): "percentage of patients at a facility whose hemoglobin (Hgb) levels were less than 10 grams per deciliter (Hgb=10)". I supported the below Hgb=10 penalty in my 2010 comments because I felt that the inherent nature of the bundle would put a tremendous downward pressure on the use of the class of ESRD anemia correcting medications called, Erythropoiesis-Stimulating Agents (ESAs): Procrit, Epogen and Aranesp.
For patients with CKD, consider starting ESA treatment when the hemoglobin level is less than 10 g/dL. This advice does not define how far below 10 g/dL is appropriate for an individual to initiate. This advice also does not recommend that the goal is to achieve a hemoglobin of 10 g/dL or a hemoglobin above 10 g/dL. Individualize dosing and use the lowest dose of ESA sufficient to reduce the need for red blood cell transfusions. Adjust dosing as appropriate.
The drug label previously recommended that ESAs should be dosed to achieve and maintain hemoglobin levels within the target range of 10 to 12 g/dL in CKD patients. This target concept has been removed from the label.
Whether the facility monitors phosphorus and calcium levels on a monthly basis.
Comments are due by end of business Monday.
In my comment I will propose that CMS stop including any Hgb numbers in its QIP and instead stake half of the QIP penalty (1% of unit reimbursement) on a new CPM: "percentage of patients at a facility whose hemoglobin grams per deciliter levels were more or less than ten percent of the Monthly Capitated Payment (MCP) Physician's target hemoglobin for that beneficiary".
In their final rule, CMS should propose using 2012 outcomes as a benchmark and implement this new CPM in 2013 effecting payment in 2015.
I believe this makes sense because CMS is paying the MCP Physician to manage their beneficiary's renal replacement therapy, including anemia management. Thus it is appropriate that the QIP motivate units to put the MCP Physician's clinical judgement into practice.
I like this approach because the dialyzor can be included in the discussion to set the target and the doctor can take the dialyzor's view on the trade off between a Hgb of 11 v a Hgb of 9 into consideration when setting an individualized goal.
One concern will be how to collect the information, how to report the MCP Physician's Hgb target. I suggest including the target with the reporting requirement to note ESA Route of Administration. Starting in 2012 units are required to include the modifiers JA (intravenous administration) or JB (subcutaneous administration) indicating the route of administration on all ESRD claims with dates of service on or after January 1, 2012 (PDF link). Along with the route of administration, units should also be required to report beneficiary's MCP Physician's Hgb target. From there it is a simple math equation to determine if the unit's performance was within 10% of the target.
The other concern is what will happen between now and when a more appropriate CPM can be implemented in 2013? With their final rule Medicare must send the message that they expect units to provide the care prescribed by the MCP Physician and act with deliberate haste to align the QIP with outcomes that matter to the dialyzed and enable CMS to meet the intent of the MIPPA (Section 153c): to motivate the safe achievement of optimal outcomes.
Medicare's publication "Preparing for Emergencies: A Guide for People on Dialysis"
Stay at home unless you are hurt, as long as it is safe to do so. Instructions for dialysis patients may be available on TV, radio, or by phone or messenger. Depending on the nature of the emergency, you might want to call your dialysis facility or doctor, because he or she might be able to help you manage this emergency.
Take a fanny pack or backpack stocked with emergency supplies, food, and medication with you if you will be away from home when severe weather or a natural disaster is predicted.
Make sure your dialysis facility knows where to find you.
Start your emergency diet (see page 22) as soon as an emergency situation is predicted or occurs, if it could delay your next regular dialysis treatment.
If you must go to a shelter, tell the person in charge about your special health needs.
If you need medical treatment, make sure your dialysis access is not used for anything other than your dialysis treatment. No one should use your access to give you fluid or medication.
Follow the instructions in this booklet to be prepared.
Make arrangements for dialysis at your destination, or have necessary equipment or supplies delivered ahead of time.
The key, in the case of a hurricane, is number 4. Start your emergency diet as soon as the situation is predicted.
The issue I have with the publication, and why I hope CMS is updating this important guide, is the emergency diet it recommends (starting on page 22). Much better emergency diet options are available, but that's a discussion for another day, right now the lede of every renal community communication to those that may be impacted by Irene should be: Start Your Emergency Diet Now.


text:
OPENING HOURSX
WEDNESDAYCLOSED
For general inquiries, please email:
jkwongacademyinfo@gmail.com
For inquiries about lion dance shows, please email:
jkwongacademy@gmail.com
J.K. Wong
Kung Fu Tai Chi
Kung Fu Instructors
NORTHERN SHAOLIN KUNG FU
WU (HAO) TAI CHI
MODERN WUSHU
PRIVATE & GROUP CLASSES
HOMESchool Calendar
Month: January February March April May June July August September October November December Year: 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050
Not all shows and performances are listed publicly. For inquiries, please contact us.
About Wu Hao Tai Chi Chuan
Spirit of Chin Woo
Belt & Jacket Colors
Adult Shaolin Curriculum
Tai Chi Curriculum
Visit Some of our Websites
Legends of Kung Fu
Wu Hao Tai Chi Chuan
Chin Woo Federation
Dragon & Lion Dance
View Larger Map Click here for directions
ADDRESS899 E Arapaho Rd Richardson, TX 75081
TELEPHONE214.878.4598
EMAILjkwongacademyinfo@gmail.com
DIRECTIONSClick here for directions
COPYRIGHT © 2013 - 2020. USA CHIN WOO FEDERATION. ALL RIGHTS RESERVED.