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RPA Comments on CMS Interim Final Rule with Comment (IFC) entitled “Conditions for Coverage for End-
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January 11, 2017 

Ms. Sylvia Burwell 
Department of Health and Human Services 
Room 445-G 
Hubert H. Humphrey Building 
200 Independence Avenue, SW 
Washington, DC 20201 

Mr. Andrew M. Slavitt 
Acting Administrator 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, 
Baltimore, MD 21244-1850 

Re: CMS-3337-IFC: Medicare Program; Conditions for Coverage for End-Stage Renal Disease Facilities--Third Party Payment 

Dear Secretary Burwell and Acting Administrator Slavitt: 

The Renal Physicians Association (RPA) is the professional organization of nephrologists whose goals are to ensure optimal care under the highest standards of medical practice for patients with kidney disease and related disorders. RPA acts as the national representative for physicians engaged in the study and management of patients with kidney disease. We are writing to offer our perspective on CMS’ above-referenced Interim Final Rule with Comment (IFC) entitled “Conditions for Coverage for End-Stage Renal Disease Facilities—Third Party Payment.” 

As noted in our comments on the corresponding Request for Information (RFI) on this issue disseminated last summer, RPA strongly supports CMS’ vigorous pursuit of its broad fiduciary mission to ensure that Medicare program management and oversight issues are addressed promptly and appropriately. 
However, we believe that the IFC lacks balance, disproportionately addresses the coverage concerns related to third party payment, and will definitively harm a segment of the Medicare ESRD beneficiary patient population that could potentially benefit from the opportunity to obtain commercial insurance The provisions of the IFC reflect an overwhelming emphasis on the perceived need to protect patients from the potential for inappropriate behavior by some members of the dialysis provider community, and will potentially reduce opportunities for patients to obtain appropriate levels of insurance coverage. Additionally, the IFC’s lack of attention to the equally inappropriate actions of some health plan issuers in proactively seeking to exclude ESRD patients is troubling and problematic. 

To be clear, RPA believes the disproportionality of the IFC, however inadvertent, to be prejudicial and potentially damaging to the lives of our patients with kidney disease. While concerns about ESRD patient steering absolutely must be addressed, the IFC is, in our opinion, certain to cause an adverse effect on charitable efforts to ensure that kidney patients have access to the qualified health plan most appropriate for them. The nation’s ESRD patient population is disproportionately low income relative to the general population, and for some individuals the financial assistance they receive from charitable non-profit organizations is the key source of support enabling them to be appropriately insured. 

Finally, we appreciate CMS’ concerns that current practice could foster potential for patient harm, however, we would submit that the IFC threatens access to and availability of charitable assistance that allows for patients to choose the coverage of most individual benefit to them and thus, is counter to the national drive toward patient-centeredness. It is worth noting that the health insurance patients can afford with the help of charitable assistance also provides coverage for the services they receive in hospitals and from specialists completely unrelated to their ESRD. Thus, there are charitable organizations in the kidney disease arena that are assisting ESRD patients to obtain care for a vast array of services needed to meet their medical needs. Threatening the availability of health coverage for these services will certainly cause harm to the Medicare beneficiaries with ESRD. 

For these reasons, RPA strongly urges CMS to delay implementation of the IFC. Instead, the Agency should develop more balanced and proportionate rulemaking that accurately and specifically targets the problems it is intended to address and does not create multiple unintended negative consequences for ESRD patients receiving charitable assistance. 

As always, RPA welcomes the opportunity to work collaboratively with CMS in its efforts to improve the quality of care provided to the nation’s kidney patients, and we stand ready as a resource to CMS in its future endeavors. Any questions or comments regarding this correspondence should be directed to RPA’s Director of Public Policy, Rob Blaser, at 301-468-3515, or by email at 


Rebecca Schmidt, DO 
RPA President 

Renal Physicians Association

1700 Rockville Pike
Suite 220
Rockville, MD 20852

Phone: 301-468-3515
Fax: 301-468-3511

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