Panel Discussion

Patricia McCarley, MSN, RN, ACNP, CNN
       Question index:
Questions received during this symposium have been paraphrased
and the answers submitted by the panelists are presented.

What are some of the positive outcomes of the CMS billing rules? Would anybody like to take that? Can anybody see anything positive?

How have any of you responded to this new CMS billing rules? Has anybody done anything yet? Could you talk a little bit about what you did?

Can anybody tell us what you did in your algorithm? We are also reacting right?

You have not noticed any change in your outcomes so far?

Do you have any patients that are over 500,000 units per month?

How many people have patients with EPO doses at that level?

What do you think we can do to maintain the patient's outcome while meeting the CMS goals?

Final comments





Panelist Responses
What are some of the positive outcomes of the CMS billing rules? Would anybody like to take that? Can anybody see anything positive?

Ms. McCarley: They gave us a nice range. It matches the K/DOQI target or range. What about decreased cost? Could occur, right? Anybody can think of anything as positive? Encourages monitoring.

Ms. Winger: I am Rebecca Winger from Nashville. For me, I was really involved with the renal care facilities adjusting to these new billing guidelines and one thing that really came out for me is it gave me a chance to reconnect with the anemia managers, and I just want to say that I have such renewed respect for all of the anemia managers out there because they are just really on top of things, and they are really sincere in trying to get good outcomes and are very on the ball in trying to meet the CMS billing guidelines as well as maintain their patient outcomes.

I think that might be one of the positive things that has come out of it. It has also forced us to relook at our protocol - someone mentioned holding the ESA dose- and actually for us that is one thing that we removed from our policy, was the hold that we had. At the same time, there are a lot of issues, and I am not going into all the issues because we are thinking about the positive right now but it also gives us an opportunity to find ways to connect better with CMS and I think something you said at the very beginning about evidence-based practice, that is what we have got to remember right now and as we work through the issues with these new billing guidelines, the way we are going to convince CMS if things are not working out well is by presenting them data and showing them - if this does have a negative impact on our outcomes, here is the data - and also to offer solutions; here is our suggestion on how we could do it better.

Ms. McCarley: I think that is really important what she just said. How many people are the anemia managers? Your job just really got more important because if there is a change for the negative or the positive, it is going to be really important to get this information to CMS because when we had the average, the HMA before, the data is what changed the policy. What is happening as we go forward will really be important.


(Back to question index) How have any of you responded to this new CMS billing rules? Has anybody done anything yet? Could you talk a little bit about what you did?

Audience member: I am just a teacher, so I just know what the clinical managers and the anemia managers did. They immediately responded. They changed their algorithms and they are addressing them earlier. They are drawing their labs earlier in the month, so that by the end of the month - it is not going to meet that guideline, but then I do not know enough because it just started April 1, 2006, but I do know that all last month they were working on changing their algorithms..

(Back to question index) Can anybody tell us what you did in your algorithm? We are also reacting right?

Audience member: We did not see it as that big a deal. I work from the Southern Indiana Group. We had to get really aggressive with the algorithms and it seems like we just nipped it in the bud right there. We had to reduce some of the worrying - that was the biggie - because we were doing hemoglobins every 2 weeks, so then we got the algorithms changed and then we were doing it twice a month. That way, we redrew all the second week of every month, so it threw us into having the hemoglobin in the last week. When the rate was changed to twice a month, then we had twice a month that we could do it. Because CMS kind of suggested that you are going to have to go back to the Dark Ages where we did blood transfusions and we did not want that, not really get into it. We have been doing it the whole month of March, took effect in April, and it has really been a smooth process.

(Back to question index) You have not noticed any change in your outcomes so far?

Audience member: No, because our algorithms are very aggressive for Hb less than 11.

(Back to question index) Do you have any patients that are over 500,000 units per month?

Audience member: No, we do not.

(Back to question index) How many people have patients with EPO doses at that level?

Ms. McCarley: One thing we have done that you could do is use subcu. The risk of pure red cell aplasia is very low in this country, and it is very low at the ESA doses or type of ESAs we use here. It is unclear if you are going to have to get 20% to 40% increased efficacy with the subcu dose. We have actually used it in our nonresponders. Whether it has worked better because you have that increased efficacy or whether it is something with the whole inflammatory process I do not know, but we have seen that work, so that might end up having to be a possibility for some of the patients.

(Back to question index) What do you think we can do to maintain the patient's outcome while meeting the CMS goals?

Ms. McCarley: I think you have come up with some ideas already. Get those hemoglobin protocols changed, the anemia management protocols changed.

Ms. Winger: I think we are going to find that we will be doing a lot more referrals, referrals that probably should have been done in the past, referrals to a hematologist and also we are going to find that we will be part of the cutting edge. We will be able to see prospectively, if we correct PTHs, if the patients will regain hematopoietic space, and the other thing is I think we all should go into our clinics and find out who is a veteran because for those patients who get veteran benefits, it will be easier for us to give them subcu if we have to.

Ms. McCarley: That is a great point she made. It is really going to force us to look at those patients on the higher doses and look for those intercurrent events or patient issues that are really contributing to this subresponse, and I think that is what CMS had in mind - in those doses that are that high, something else is probably going on that we are not identifying. If we did identify it, besides just pushing EPO, EPO, ESA, ESA, we may even get a better response, and those patients will have a better quality of life.


(Back to question index) Final comments

Ms. Winger: I thought of one more thing that we did - I do not know if it is unique for a renal care group - but we decided for physicians who felt like they really did need to maintain over 500,000 units a month or hemoglobin over 13, we set up a process, an approval process through our pharmacy and therapeutics committee, and it works well because at least the physician has a recourse, somewhere to go when they feel strongly about how they want to dose their patient, and at the same time when they approach the P and T committee, it is an opportunity for them to maybe look at that patient in a different way. Maybe they are not managing iron as well as they should or it helps you discover new ways to manage that patient. That is one thing that we did.

Ms. McCarley: I have a lot of case studies, and I have done these with groups before. They can be really effective with your staff to sit down and go through, identify intercurrent events, what information do you want to know, and what are the therapeutic options, and they may be helpful to teach your anemia managers about some of the things that they are going to have to really start looking at, but in view of the time and where we are and that it is late, I will just close.

In conclusion, I want you to know I think that anemia affects patients, even small amounts sub-11, we know, increase risk of morbidity and mortality. Trend, trend, trend, trend, trend... together, together, together. Look at the hemoglobin dose, the ESA dose, and the iron parameters and look at them all together. To have a separate iron protocol and anemia protocol, it just does not make sense.

You are the anemia case manager, and I think that instead of being the anemia managers, we are the anemia case managers because we have to look at the patient in his or her entirety. It is not just that we are managing numbers, we are managing this whole huge clinical event, and we need to be patient centered. I think that was the focus for tonight.

Thank you very much.


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