Fall 2010 Member e–Newsletter

Table of Contents

• Understanding and Adapting to Bundling
• Chair’s Corner
• Scientific Poster Design—All You Want to Know but Are Afraid to Ask
• Disease Prevention and the Affordable Care Act of 2010 (ACA)
• Member Spotlight: Tiffany Troxel, PA–C, MSHS, MPH
• Educational Stipends to SCM11 Available
• Update: Sydney the Kidney

Understanding and Adapting to Bundling

Lynn Poole, FNP–BC, CNN

End–Stage Renal Disease (ESRD) Prospective Payment System (PPS) (also known as “Bundling”)
Included in the Medicare Improvement for Patients and Providers Act (MIPPA) of 2008 was the requirement for the development and implementation of a PPS for Medicare beneficiaries with ESRD receiving dialysis services. The first phase of the new payment system will begin on 1/1/2011 and with that will come changes in the way the care of patients with ESRD is reimbursed. This change in the composite rate will now include additional components such as medications, labs and other services that were previously paid separately. With any new Medicare payment structure, initially there will be a new level of complexity to adjust to on a day-to-day basis and more changes occurring over the long term. In addition, as of 2012, new requirements for quality improvement will be linked to full reimbursement.

The first date–sensitive action occurred on 11/1/2010. Dialysis providers were required to declare to CMS whether they planned to adopt the bundled payment for all patients and facilities on 1/1/2011 or to use a “blended rate” that will phase in over the next three years. But no matter the choice made by the providers, we can expect to see changes in how care is delivered. As APs on the front lines, there are certain areas of care to pay special attention to as providers implement the new payment system. After consulting with several dialysis providers, several areas of focus emerged related to how APs may be called upon to work with their dialysis providers and colleagues for successful implementation and maintenance of the PPS in the short and long term. Most providers do not anticipate significant changes in the delivery of care to the individual patient.

AP Areas of Focus
Laboratory Tests:

• All APs should work with their dialysis providers to develop a clear understanding of what laboratory tests are or are not included in the PPS as ESRD–related labs.
• CMS is developing a modifier for laboratory tests not related to ESRD that may be billed separately when clinically indicated and with proper documentation of the necessity.
• Proper and clear documentation of why a laboratory test is being ordered will be crucial to ensure proper and prompt payment to the providers
• A dialysis provider may contact the AP if the documentation is not clear or more information is needed

• All APs should work with their dialysis providers to develop a clear understanding of what medications are included in the PPS and how they are and will be utilized in the dialysis clinic
• Clinical results should be monitored closely if medication changes are made such as:
  • Medication choice
  • Dosage
  • Route of administration
• Drugs not related to ESRD may be billed and paid separately from the PPS but must be clinically indicated and documented properly for the intended use
• A dialysis provider may contact the AP if the documentation is not clear or more information is needed

Proper Coding and Documentation of Acute Illnesses:
Acute clinical conditions in patients with ESRD are often documented as ESRD when the diagnosis is an acute condition not related to or separate from ESRD. This is one area where APs can assist dialysis providers in making certain that they aren’t expected to pay for services unrelated to ESRD because of improper or incomplete documentation.

In Conclusion
As we enter into this new phase of payment for care of dialysis patients, we are entering a period of uncertainty when all are trying to determine how to implement this with the least disruption to the patients and their providers. As APs, we are excellent at adapting to new situations for the betterment of the care for the patients we serve. The PPS is here to stay and, as with anything new and of this magnitude, some things will go well and some won’t. This will require patience, diligence and good humor on the part of all health care team members invested in the delivery of care to patients with ESRD.

In subsequent newsletters, we will offer more information on what ESRD services are included in the PPS and on the finalized proposed rule for the Quality Incentive Program that defines the indicators to measure outcomes and demonstrate opportunities for improvement. We will be asking you to share your unique experiences with us regarding the implementation of the PPS and any changes, perceived or real, resulting from its implementation.

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Chair’s Corner

Kim Zuber, PA-C, MSPS

The fall is waning, the holidays are approaching and your CAP Executive Council has been hard at work preparing for the NKF 2011 Spring Clinical Meetings (SCM) in Vegas. We have several projects in the planning stages that we know will be useful for APs in nephrology.

Dialysis Essentials builds upon the CKD Essentials program that Lisa Farris (NP, DNP extraordinaire) unveiled last year at the Orlando meeting. Dialysis Essentials, coordinated by Marty Bergman, PAC, and Lisa, is targeted at the new AP in nephrology. This is a CME/CEU accredited series of slides that review what an AP needs to know that first year in practice. It is a quick and dirty overview to help APs feel more confident in the dialysis unit. The program focuses on many of the situations which arise during the dialysis process but also addresses writing orders, nutrition, and non–dialysis related infections. We took to heart your comments from last year asking that our Essentials program offer CME/CEU credits. This year, we went through the certification process and the CME/CEU is attached to the program. Next year, Transplant Essentials will round out our trifecta of Essentials programs.

Since Essentials has been so popular, we wanted to do something for the experienced AP. Laurie Benton (CME Chair and education guru) has joined with Dr. Charlie Foulks from the University of Oklahoma to secure a $100,000 grant from Roche (thank you Roche!) to pay for the development and distribution of an online program of nephrology education for APs (and actually any MD, PA, NP or CNS). We are just in the beginning phases of this project. There will be more details to come including a request for authors for sections of the program.

Which brings me to my main request: What do YOU need? We, the Executive Committee, are only as good as the input from our Council membership. If you tell us what your needs are, we can better develop programs to support you. I will be hosting a Town Meeting at the Vegas Spring Clinical meetings and I hope to see many of you there. It will be a chance to actually talk and share what is happening for APs nationwide. We need your input for this Council to be relevant to you and your practice. Help us make it “the best it can be” (to borrow a phrase).

Scientific Poster Design—All You Want to Know but Are Afraid to Ask

Beth Wilkening, PA–C

With SCM11 looming large on the horizon, maybe you have harbored a desire to participate in the poster sessions. Having a good research topic with interesting results is a start, but there is a better way to get your results and message out to conference attendees.

We’ve done some internet browsing and found some great information to help you put together a great poster. Colin Purrington, PhD, Evolutionary Biology Associate Professor at Swarthmore College put together some helpful guidelines for his students on a website. In order to get the full impact of Dr. Purrington’s presentation, including many more tips and ideas, pictures, diagrams, and links to other sites, please visit his page, Advice on Designing Scientific Posters.

Sections on your poster should include the following:

• Title (maximum 1–2 lines)
• Introduction (200 words): State your hypothesis clearly and put your project in context with current guidelines/published literature.
• Materials and Methods (200 words): Include figures, tables, photos, flowcharts, and the type of statistical analyses used.
• Results: Did it work? Put qualitative results in the first paragraph,and data analysis in the second paragraph.
• Conclusions (300 words): Did your results support your hypothesis? Discuss relevance and future directions.
• Literature Cited (10 citations max): Use required standard format.
• Acknowledgments (40 words): Funding, contributions such as equipment donation and statistical advice, printing assistance, disclosures for conflicts of interest/commitment.
• Further Information (20 words): Your email/snail mail address, website, URL.

**Do NOT put your abstract on your poster!!**

Design Tips

• Draft, redraft, and redraft again. Do a rough draft at least a month before it is due, to allow sufficient time for critique and revision.
• Use a single operating system for your whole poster (either PC or MAC) or you may lose files and have printing issues. Use a software template, such as PowerPoint. Templates are available on the internet, and are easily downloaded for use. Dr. Purrington’s site offers several designs.
• Too Much Information: Keep word count under 1000 words or people will not stay to read it.
• Formatting:: Do NOT use colons in titles, Use the sentence case, with standard naming conventions; do not punctuate section headers; limit blocks of text to ≤ 10 sentences; and decrease font size for acronyms and numbers.
• Color: Limit color and use symbols and patterns instead. Avoid using red and green together. To see what people with color deficiencies will see when they look at your poster, run your templates through a color vision check service.

Printing

• Get your presentation done in time so you do not have to do a rush–job for printing.
• If you have a sponsor who will take your draft, print it into a poster, and send it directly to the conference, be sure to thank the sponsor profusely and include an acknowledgment (see poster sections, above).
• Do not re–invent the wheel. Ask someone in your department who has been there. If you are employed by an academic institution, you may be able to use the printing office on campus. Office supply stores (especially ones located nearby to campuses) now have employees dedicated to printing larger format posters. Tip: For small change you can print 8x10 copies of your poster to hand out — really impressive!

Timelines

Know your time frames and deadlines. Remember it always takes longer than you think.

SCM11

Use this section to provide your e–mail address, Web site address, and, if applicable, a URL where readers can download a PDF version of the poster.

Tip In PowerPoint, format the URL so that it isn’t in color and underlined. Maximum length: approximately 20 words.

Abstract Deadline is December 3, 2010

Submit your abstract online today.

References:
Purrington, C.B. 2009. Advice on designing scientific posters. http://www.swarthmore.edu/NatSci/cpurrin1/posteradvice.htm. Accessed [01Nov2010].

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Disease Prevention and the Affordable Care Act of 2010 (ACA)

Dolph Chianchiano, JD, MPA
NKF Senior Vice President for Health Policy and Research

Americans receive only about half of the preventive medical services that are recommended and health care professionals who are proponents of disease prevention argue that the U. S. health care system has been focused too long on acute episodes of care rather than on interventions that could avoid the need for treatment in the first place.

In a recent regulatory publication, the U. S. Department of Health indicates that the underutilization of preventive services stems from three main factors. First, due to turnover in the health insurance market, health insurance issuers do not currently have incentives to cover preventive services because the benefit of those services may only be realized in the future when an individual may no longer be covered by that company’s insurance. Second, many preventive services generate benefits that do not accrue immediately to the individual that receives the services, making that individual less inclined to assume the immediate costs of the intervention. Third, some of the benefits of preventive services accrue to society as a whole, and thus do not get factored into an individual's decision-making as to whether he should obtain such services.

That being said, the general public seems to be becoming more inclined to focus on health promotion. One year ago, Trust for America’s Health and the Robert Wood Johnson Foundation released findings from a public opinion survey indicating that 71 percent of Americans favored an increased investment in disease prevention, which was also one of the most popular components of the health reform legislation then being debated in Congress.

NKF members should know about the many provisions that were included in health care reform legislation, enacted as the Affordable Care Act of 2010 (ACA), that break new ground in the effort to prevent chronic disease and improve public health.

Section 4002 of ACA establishes a Prevention and Public Health Fund, making it possible for the federal government to devote substantial resources for this program, starting with $500 million for fiscal year 2010, increasing gradually to $2 billion in the 2015 fiscal year and each year thereafter. Among other things, the Fund can be tapped for Community Transformation Grants which will be measured by (i) changes in weight; (ii) changes in nutritional intake; (iii) changes in physical activity; (iv) changes in tobacco use; and (v) changes in emotional well-being and overall mental health.

Starting January 1, 2011, Medicare will cover, without cost sharing, an annual wellness visit that includes a health risk assessment and a customized prevention plan. Similarly, section 4206 directs the Secretary of Health to establish a pilot program to test the impact of providing an individualized wellness plan designed to reduce risk factors for preventable conditions identified by a comprehensive risk factor assessment to at-risk populations who utilize federally–qualified community health centers.

Section 4108 of the Act directs the Secretary of Health to award grants to States to provide incentives to Medicaid beneficiaries who successfully participate in a healthy lifestyles program and demonstrate changes in health risk and outcomes. The program will focus on the needs of Medicaid beneficiaries to achieve: ceasing the use of tobacco; controlling or reducing weight; lowering cholesterol; lowering blood pressure; or avoiding the onset of diabetes or improving management of diabetes. The statute authorizes $100 million for this program, to be spent over 5 years.

Section 4202 authorizes the Secretary, acting through the Director of the Centers for Disease Control and Prevention, to award competitive grants to health departments and Indian tribes for five–year pilot programs to provide public health community interventions, screenings, and when necessary, clinical referrals for individuals who are between 55–64 years old. Grantees must design strategies to improve the health status of this population through community–based public health interventions. As with the programs listed above, intervention activities may include efforts to improve nutrition, increase physical activity, reduce tobacco use and substance abuse, improve mental health, and promote healthy lifestyles among the target population.

Although kidney disease is not specifically mentioned in any of these provisions, the emphasis on improved management of diabetes and hypertension and the factors that predispose at–risk populations to diabetes and hypertension (and the progression of these diseases) should help to reduce the incidence and prevalence of chronic kidney disease.

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Member Spotlight: Tiffany Troxel, PA—C, MSHS, MPH

Love at first sight is alive and well for Tiffany Troxel. After following up on a lead from a friend about a position in Guam, Tiffany found it on the map, traveled there, fell in love and could not be pried away. Seattle–born and Idaho–raised, Tiffany graduated from Idaho State University with a degree in zoology. She spent two years in Guinea, West Africa, with the Peace Corps before returning to school at George Washington University and graduated with a dual degree. She holds a Master of Science in Health Sciences and a Master of Public Health, with emphasis on maternal/child health.

Tiffany is one person who seems to have done it all. As a PA, she has worked in urology, bone marrow transplant, and pediatric endocrinology as well as internal medicine. The ad for a position in internal medicine/hemodialysis was tempting and when Tiffany went to Guam in 2007, knew she had found her home, and moved permanently. Luckily, her long term partner, Cindy, landed a job at Andersen Air Force Base as the executive chef for Top of the Rock Club.

Tiffany’s job provides her the same variety many of us have stateside. She follows 300 patients in three dialysis clinics and also works in an internal medicine/women’s health clinic. Similar to the U.S., a large number of her patients come into the Emergency Department with kidney failure, and diabetes and hypertension are common. She estimates most of her patients are in their forties and fifties.

The lack of resources is a major challenge. In the three years she has been there, only two patients have received transplants. The closest transplant centers are in Manila or Hawaii and the obstacles are overwhelming for her patients. Most of her patients are uninsured and she lacks many of the resources some of us take for granted such as access to medications.

Tiffany believes she can make a difference and is active in a coalition which creates education programs for the grade schools. These programs focus on healthy lifestyles—healthy eating, weight control, smoking avoidance. Reading the description of her professional activities, one would never guess she also has time to snorkel, kayak, dance, and sing karaoke. Her home is on a cove of the Philippine Sea so the water is her backyard.

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Educational Stipends to SCM11 Available

Deadline to apply: January 7, 2011 … Apply Online

As part of its commitment to support continuing education in the area of nephrology, the NKF–CAP will accept applications from regular CAP members for educational travel stipends of up to $500 to assist in attending the 2011 NKF Spring Clinical Meetings (SCM11) in Las Vegas, NV. Stipends will be awarded based on the merit and completion of the application form as specified. Persons presenting original research or Abstracts may be given preference. The amount of the award will be determined based on travel distance. The completed application form must be submitted online by January 7, 2011.

The applicant must meet the following criteria:

1. The applicant must be a regular member of the NKF-CAP.
2. Award recipients must attend the majority of Advance Practitioner or Physician sessions at the NKF 2011 Spring Clinical Meetings.
3. Applicants are required to summarize one (1) session that they attend and submit the summary paper to the Publications Chair by May 18, 2011. These summary papers will be considered for publication in CAP’s quarterly e–newsletter.

Don’t miss out on an opportunity to learn the latest in nephrology and to meet colleagues from all over the United States. Student members are encouraged to apply.

Applications are due January 7, 2011. Apply Online
Applicants will be notified regarding the status of their application via email by January 31, 2011

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Update: Sydney the Kidney

It is with great sorrow we announce the disappearance of Sydney the Kidney. He was last seen leaving Wisconsin and headed for California. Rumors abound as to his current whereabouts. Some believe he has entered a witness protection program. Others declare he is a secret agent who has gone undercover for the sodium squad. Still others sorrowfully believe he is being held for ransom. Others, to our horror, speculate he is being force fed non–steroidal anti–inflammatory drugs in hopes of inducing kidney failure.

The facts as we know them are, Sydney had a great time with Linda Doeckel and her colleagues in Wisconsin. They grew to love Sydney and hated to see him go, but knew it wasn’t fair to keep him from others, so off to the post office he went. If Linda had only known that he would be lost to all once he left Wisconsin, she would have never let him go. Supposedly he was heading west to California to see Elaine Go in Laguna Niguel, CA, but unfortunately he never made it.

Whatever the case, being Advanced Practitioners, we always have a plan B. Sydney was secretly cloned and his replacement will soon debut… further proof that you can’t keep a good kidney down.

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