eyes and ears
Joined: 12 Apr 2003
Posts: 24
Posted: Fri Dec 12, 2003 8:12 am Post subject: NKF letter
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<
>December 5, 2003 <
>Hon. Charles E. Grassley<
>Chairman<
>Committee on Finance <
>U. S. Senate<
>Washington, DC 20510 <
><
>Dear Sen. Grassley: <
>The National Kidney Foundation (NKF) appreciates and shares your concern for the quality of care experienced by dialysis patients in the United States. Because of your interest in the welfare of this patient population, the General Accounting Office (GAO) has issued two reports, "Medicare Quality of Care: Oversight of Kidney Dialysis Facilities Needs Improvement" (June 2000) and "Dialysis Facilities: Problems Remain in Ensuring Compliance with Medicare Quality Standards" (October 2003). This letter constitutes the NKF's response to these GAO reports. <
><
>For its part, NKF's concern for the well being of dialysis patients has resulted in our commitment to a continuing clinical practice guideline development project, originally called the Dialysis Outcomes Quality Initiative (DOQI). Few guidelines have received the
oad support from health care providers than the DOQI guidelines have. We are proud of the impact these guidelines have had on care of patients on dialysis in general, dialysis adequacy, vascular access, anemia management and mortality in particular. While there have been regional variations in the degree to which the clinical care of dialysis patients has improved since the guidelines were issued in 1997, most providers have em
aced the DOQI recommendations. <
><
>Despite this progress, the most recent GAO Dialysis Report notes: <
>* At 512 facilities, 20% or more of patients receive inadequate dialysis. <
>* Nearly 1,700 units fall short of meeting the goal of having at least 20% of patients with hematocrit greater than 33. <
>* 19% of patients were dialyzed for extended periods of time using catheters. <
><
>We suggest caution in interpreting these findings. While in some cases they may reflect less than optimum care in dialysis clinics, these outcomes may also be attributable to complex patient mix, the confounding impact of co-morbidities, which are increasingly common in this patient population, and the consequences of inadequate pre-dialysis care. A few examples will illustrate the complexity that surrounds the interpretation of these statistics: <
>1. With regard to patient mix, new ESRD patients, whose medical conditions have not been stabilized, typically constitute 20% of the patients in a given facility. It generally takes up to six months to a year to
ing these patients into the optimum range recommended by DOQI. Consequently, at any given time, 20% of patients are unlikely to meet the DOQI targets because of their being new to dialysis. <
>2. The majority of patients have not had a permanent vascular access placed or even attempted prior to starting dialysis. In addition, a majority of patients have diabetes and/or cardiovascular disease, limiting the likelihood of a permanent vascular access. <
>3. Because 40% of the prevalent dialysis patients have diabetes, many patients have compromised vasculature and inadequate vascular access which can limit dialysis adequacy. <
>4. The vast majority of patients start dialysis with extremely low Hematocrit levels and iron deficiency. The vast majority of these patients have never received treatment with erythropoietin or iron prior to dialysis. It often takes up to six months to
ing these patients into the desired Hematocrit range with effective treatment. In addition, systemic inflammation may impinge upon response to anemia therapy. <
>5. Finally, the choice of vascular access is often related to the lack of third party payment during the months before initiation of dialysis. <
>Nevertheless the National Kidney Foundation is convinced that opportunities exist for continuing quality improvement in dialysis adequacy, anemia management and placement and preservation of vascular access. We note that the ESRD Networks, working with the Institute for Healthcare Improvement, have embarked on a Vascular Access-Quality Improvement Project and believe that this initiative can help to enhance the percentage of dialysis patients with permanent natural accesses. NKF is studying the problem of dialysis patients who remain anemic even though they are receiving erythropoietin therapy. We will examine this issue in revised K/DOQI anemia guidelines that will be issued by the end of <
>2004. We also hope that CMS and other insurers and purchasers of care will address coverage for vascular access placement for individuals who are not entitled to Medicare before they begin dialysis treatments. <
> Reimbursement policy also has a role to play in two problems cited in the 2003 GAO Report, e.g., "Inadequate Clinical Management" and "Insufficient Professional Involvement in Care of Dialysis Patients." In the Report to Congress, "Toward a Bundled Outpatient Medicare End Stage Renal Disease Prospective Payment System," the Department of Health and Human Services acknowledges that the reimbursement rate Medicare pays to dialysis providers does not cover their cost of providing dialysis services, of which personnel expenses are a large component. There are additional opportunities for CMS to address "Inadequate Clinical Management" and "Insufficient Professional Involvement in Care of Dialysis Patients." The original plans for Dialysis Facility Compare (DFC) included publication of patient/staff ratios for individual clinics but that data point was unfortunately eliminated in the final iteration of DFC. The Medicare Conditions of Coverage for ESRD Providers have not been revised since 1976. CMS should move forward with revisions that will help address adequacy of staffing levels at dialysis clinics. <
><
>With regard to those dialysis providers whose level of care is sub-optimum, the highest priority should be given to correcting the examples of condition-level deficiencies and oversight problems cited in the 2003 GAO Report, such as: <
>* Medication Errors <
>* Improper Use of Reusable Dialysis Equipment <
>* Contamination of Water Used for Dialysis <
>* Repeated Citations for the Same Deficiency <
>* Inadequate Training of State Surveyors <
>* Limited Communication between ESRD Networks and State Survey Agencies <
><
>We concur with several recommendations by the GAO to address these problems and have taken initiatives that would lead to the desired changes. For example: <
>1. The GAO recommends that CMS assess civil monetary penalties for facilities with condition level deficiencies in successive surveys. Such a change in policy was approved by the NKF Board of Directors when it met on September 24, <
>2001. <
>2. The GAO recommends that more ESRD training opportunities be made available to state surveyors in a variety of venues, noting that states whose surveyors have limited ESRD experience tend to report fewer deficiencies than state surveyors with more experience. NKF hosted special educational programs for state surveyors at the Foundation's Annual Clinical Conference in Dallas in April 2002 and in Chicago in 2003 and is prepared to expand these educational programs. <
>3. The GAO recommends that CMS should establish goals to reduce time between surveys for facilities with condition-level deficiencies. This is consistent with a recommendation discussed at the NKF Board of Directors meeting on April 15, 2000. <
>4. The National Kidney Foundation also endorses the GAO recommendation that the ESRD Network regulations be revised so that they can share facility-specific data with state survey agencies on a routine basis. <
><
>Thank you very much for your leadership. Please feel free to call upon the National Kidney Foundation if we can be of any assistance when you are developing legislative proposals based upon these GAO Reports. <
><
>Sincerely, <
>Brian J.G. Pereira, MD<
>President<
>
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Worker Bee
Joined: 29 Oct 2002
Posts: 28
Posted: Fri Dec 12, 2003 9:38 am Post subject: NKF
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Does anything else need to be said about the NKF being PRO INDUSTRY? They are repeating what the industry wants the government to hear, hook, line and sinker! It makes me sick to see listed all the excusses as to why patients here in the U.S. have such a high mortality rate and poor dialysis outcomes. Yes, the only thing to help is throwing more $$$$ at an industry who reports HUGH profits each quarter! May I puck now?:">
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cks
Joined: 30 Jun 2003
Posts: 12
Posted: Fri Dec 12, 2003 11:41 am Post subject: RE: Worker Bee
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What you talking 'bout willis? Is there a single unfactual statement in the letter? WHere did they say throw around money?
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BRLA
Joined: 08 Nov 2003
Posts: 22
Posted: Sat Dec 13, 2003 6:17 am Post subject: NKF Letter
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Right on, Worker Bee! <
><
>Patients and their families are so tired of reading and hearing "excuses" for poor dialysis outcomes and survival rates in the U.S. (such as those in NKF's letter, #'s 1-5). We are inclined to digest that expressed in an article: Kjellstrand, Carl M. & Blagg, Christopher R. (2003); Differences in Dialysis Practice Are the Main Reasons for the High Mortality Rate in the United States Compared to Japan. Hemodialysis International 7(1), 67-71 -- (accessed via
http://www.blackwell-synergy.com/) -- as well as that info provided in other Nephrology professional periodicals.<
><
>Inclination is based on actual experiences in dialysis facilities, characterized, too often, by inadequate dialysis time, fast/jiffy-lube procedures, understaffing, and minimally trained healthcare team members.<
><
>While appreciated for what it did contain, the GAO Report, in my opinion, did not go far enough. Perhaps with increased frequency of surveys (utilizing trained and competent surveyors), and timely and accurate collection and interpretation of data, CMS and the dialysis industry, including organizations such as NKF, will concede to evidence that something is drastically wrong with dialysis in this country and, ideally, be about making needed changes to support recognition of the U.S. as the greatest country in the world.
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mole
Joined: 20 Nov 2003
Posts: 7
Posted: Sat Dec 13, 2003 9:18 am Post subject: NFK
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the NFK is funded and own by the dialysis and drug industry need you say more.
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FYI
Joined: 15 Feb 2003
Posts: 72
Posted: Mon Dec 15, 2003 4:47 am Post subject: Sen Grassley
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First of all Grassley is pro industry and has had all the information for the past 5 1/2 years. We have had the personal experience with his rhetoric for the cameras and the limited outrage that ends when the camera does.<
>WE were headed for the House side before the newest GAO report was released.<
><
>They all have worked in unison to continue these abuses. It is election year and for one, I am not concerned with the NKF nor the Grassley rhetoric. I would worry, if we werent headed in another direction. It has been the same status quo for the last 30 years. Nothing will change with these guys.<
><
>The NKF will have to answer as will others in this industry, after all they are the industry and have always been there for them. Not for you.<
><
>Its amazing that this industry and the government have just woken up at this time. We called it, and stated all changes have to be done before the next election. We have not stopped and are on firm ground. I am confident that we will have the last say, and we were not paid off by any of the industry. Remember the NKF had many documents for over 5 years and did nothing.That speaks volumes.<
>Arlene<
><
