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From page 133... ... The Social Security Amendments of 1972 also established an entitlement to Medicare for most Americans individuals with permanent kidney failure. Medicare coverage meant that dialysis and kidney transplantation services would be covered as well as other medical services covered under the Medicare program. Read the entire page →
From page 135... ... It did not, however, create an entitlement for all.2 Consequently, one question that Congress asked in its OBRA 1987 charge dealt with access problems of ESRD patients who are not eligible for Medicare coverage. The congressional charge also asked that the study consider access problems of Medicare-covered ESRD beneficiaries. Read the entire page →
From page 136... ... The report, using 1981 data, estimated that of the 55,000 ESRD patients in the United States who received dialysis treatments from Medicare-certified dialysis facilities, about 8,500 were not then entitled to Medicare benefits. Half of these unentitled patients were awaiting entitlement to the Medicare program and approval was expected: For these individuals, Blue Cross and other private insurers were the major sources of support for 50 percent, whereas Medicaid was the primary payment source for another 27 percent. Read the entire page →
From page 137... ... Although aliens not legally residing in the United States may present themselves for treatment as ESRD patients, and may represent a significant proportion of the noneligibles, as a practical matter they are seldom eligible for either Medicare or state Medicaid coverage. Citizenship or resident alien status is effectively a requirement for Medicare and Medicaid eligibility for ESRD treatment.3 Eligibility for Medicare coverage for ESRD is a function of Social Security insured status, which results from active labor force participation. Read the entire page →
From page 138... ... In the 3 years from 1987 to 1989, however, that percentage increased to 7.2, 7.3, and 7.5 percent. Although the percentages were stable until recently, the absolute numbers of noneligible ESRD patients more than doubled from 3,697 in 1980 to 8,722 in 1989. Read the entire page →
From page 139... ... This is dramatically shown in the cases of Arizona and New Mexico. In 1988, Arizona had 222 noneligible ESRD patients (15 percent) Read the entire page →
From page 140... ... Most important, they do not permit examination of the effect of eligibility status on patient outcomes. Payment Sources Potential sources of financial support available to noneligible ESRD patients are personal resources, private health insurance, or public programs. Read the entire page →
From page 141... ... ACCESS PROBLEMS OF ESRD PATIENTS 141 TABLE 7-3 Percentage of Non-Medicare Patients Among Total Dialysis Patients, by City Versus State, and Year, 1980-87 City and State 1980 1981 1982 1983 1984 1985 1986 1987 Boston 8.7 8.2 8.2 7.6 7.3 7.3 12.9 10.1 Massachusetts 5.7 5.8 5.8 6.3 6.7 5.7 8.7 8.0 Chicago 10.6 9.8 8.9 8.4 9.4 11.8 15.8 10.6 Illinois 6.5 5.6 5.5 5.3 6.3 8.0 9.2 7.0 Cleveland 5.7 4.6 3.8 4.1 3.0 9.5 9.5 8.6 Ohio 4.8 5.1 5.1 5.2 5.4 7.1 5.6 5.6 Dallas 7.5 5.0 5.4 7.2 8.0 9.6 10.0 9.0 Texas 7.0 6.0 5.2 5.8 5.6 6.4 5.9 5.9 Detroit 8.5 8.2 11.2 8.3 11.2 8.2 8.0 7.9 Michigan 6.2 6.4 6.5 7.0 8.2 7.5 7.7 6.7 Indianapolis 13.2 12.6 10.8 3.1 4.7 0.8 4.1 2.4 Indiana 7.1 6.2 5.7 1.9 2.7 1.1 2.4 3.1 Los Angeles 11.8 11.9 10.5 9.5 13.6 13.5 15.9 14.3 California 7.8 7.2 7.6 7.6 8.0 8.4 8.5 10.1 Miami 9.0 12.0 12.6 12.1 11.8 9.8 9.9 10.0 Florida 4.5 4.8 5.2 5.4 5.4 5.3 5.9 4.9 New York City 11.5 10.9 8.2 9.2 10.8 12.5 11.5 11.8 New York 7.9 7.5 6.6 6.8 7.5 7.8 8.4 9.0 Newark 6.1 5.7 7.0 10.5 7.8 8.4 17.4 7.1 New Jersey 4.8 3.9 4.0 4.8 5.6 5.2 6.0 8.5 Philadelphia 8.2 6.5 6.6 7.1 7.8 8.2 8.1 9.1 Pennsylvania 6.6 5.1 5.4 5.4 5.7 6.2 4.8 5.8 Phoenix 13.8 8.6 12.9 8.9 7.9 10.2 10.1 10.6 Arizona 16.2 16.1 16.2 14.8 12.3 13.7 12.2 12.8 Washington, D.C. 29.1 27.5 15.9 17.4 16.3 20.6 15.5 26.4 NOTE: As of December 31 of the calendar year. Read the entire page →
From page 142... ... Eight of the 10 surveyed state Medicaid programs reimburse for outpatient dialysis treatment at payment levels ranging from $110 to $150 per session. Illinois, Maryland, and Massachusetts pay the equivalent of the Medicare composite rate under their Medicaid programs. Read the entire page →
From page 143... ... Given the budget pressures that many state governments face at the present time, it is probably not realistic to expect that these state kidney programs will increase their financial support for noneligible ESRD patients or that more states will add such programs.6 Other ESRD Programs The INS is responsible for providing comprehensive medical care to Native Americans living on reservations. IHS health care benefits vary Read the entire page →
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From page 146... ... A DVA dialysis program that is shrinking in numbers of patients and expenditures could not absorb the growing number of Medicare noneligible ESRD patients, even if veterans' eligibility were not a problem. State Medicaid programs, then, constitute the first line of financial support for ESRD patients who lack Medicare coverage. Read the entire page →
From page 147... ... 147 oo o oo C~ ._ Ct cn ._ C~ Ct �fi s~ t4o" C~ s~ . Read the entire page →
From page 148... ... Fourth, several major sources for financing the ESRD care of reported noneligibles, such as the DVA, the IHS, and state kidney programs, are stable or shrinking. State Medicaid programs have thus become the payer of last resort for reported noneligible ESRD patients. Read the entire page →
From page 149... ... Current Medicare entitlement criteria do not apply to the treatment of children with progressive irreversible renal insufficiency until they reach the ESRD stage. Consequently, many pediatric patients enter the Medicare ESRD program suffering from potentially avoidable clinical consequences of severe chronic renal failure. Read the entire page →
From page 150... ... Elderly Patients In the initial year of the Medicare ESRD program, only 5 percent of prevalent ESRD patients were over age 65 (Rettig, 19801. This proportion has grown over the years to nearly 40 percent of the incident ESRD population and over 25 percent of the prevalent population. Read the entire page →
From page 151... ... However, respect for patients should lead all physicians and caregivers to place a high value on conveying information to patients about their health status and treatment options. Although peer education is very useful to new ESRD patients, they rely heavily on their physicians to educate them and their families. Read the entire page →
From page 152... ... Ninetyfour percent qualified for Medicare coverage and nearly 80 percent had some additional insurance, either public or private. These ESRD patients did not differ in Medicare coverage by age or gender, but 95 percent of white patients had such coverage compared to 90 percent of black patients. Read the entire page →
From page 153... ... It also directed the General Accounting Office to study the effects of this provision on patients before any further extension is considered. Support for Medicare as secondary payer for ESRD patients derives from two basic sources. Read the entire page →
From page 154... ... The committee commends the Congress for directing the Comptroller General to study the effects of extending the secondary-payer provision to 18 months for ESRD patients. The committee recommends that the focus of such a study be the effects on patient access to treatment modalities and services and on patient outcomes. Read the entire page →
From page 155... ... As a consequence, Medicare policy is not geared to returning individuals to work, and HCFA has few statutory, organizational, or financial resources to help individuals do so. In fact, in the 1972 statute, ESRD patients are "deemed to be disabled" for purposes of Medicare coverage. Read the entire page →
From page 156... ... reported on disparities in the use of health services and in health status between blacks and whites. A significantly higher proportion of blacks had not seen a physician within a oneyear period. Read the entire page →
From page 157... ... of hypertensive ESRD patients also showed that low socioeconomic status was an independent predictor for the development of ESRD; controlling for it did not eradicate the significant influence that black race had on the occurrence of kidney failure. Little research has been performed in the Hispanic community regarding access to preventive health care. Read the entire page →
From page 158... ... The substantial increase of the utilization rate over time in the CON states does not appear to be due solely to the growth of the patient population in those states. If anything, the patient population in CON states grew more slowly than in non-CON states between 1984 and 1988. Read the entire page →
From page 159... ... 159 oo oo .� _ Ct _~ ~ .� Ct �(,, � Ct ~ ~ s~ o ~ ~ Ct on of Cal of o ._ Ct ._ Ct ._ C) Read the entire page →
From page 160... ... A significant increase in dialysis facilities and stations occurred: From 1984 to 1988, facilities increased by almost 70 percent, and stations increased over 60 percent, whereas the patient population increased by only 34 percent. This led to a 10 percent decrease in utilization from 461 treatments per station in 1984 to 417 in 1988. Read the entire page →
From page 161... ... removed, the number of dialysis facilities increased substantially: 25 new dialysis facilities began to operate in 1986, representing a 31 percent increase from the previous year. This suggests that CON regulations also play a major role in explaining differences in facility growth across states. Read the entire page →
From page 162... ... have shown that competition in ESRD program increases the amenities that dialysis patients receive. Fourth, CON regulation provides no assurance of quality and actually shields facilities from the need to compete on the basis of quality. Read the entire page →
From page 163... ... Under the Office of Research, this project included Medicaid records for 3, 4, or 5 state programs, depending on the year; under the Actuary and BDMS, it included more states. However, merging these data with Medicare data to link the records of dual-eligible and noneligible ESRD patients was judged to be a large and difficult research effort that was beyond the scope of this study. Read the entire page →
From page 164... ... 13. See State of Connecticut, Regulation of the Department of Health Services, � 19-13-DSSa, for the licensure of an outpatient dialysis unit and standards for in-hospital dialysis units. Read the entire page →
From page 165... ... 1990. Analysis of Data Related to the 1976-1989 Patient Population: Treatment Characteristics and Patient Outcomes. Read the entire page →
From page 166... ... 166 JO Ct so o s~ Ct C) Read the entire page →

From page 133...

... The Social Security Amendments of 1972 also established an entitlement to Medicare for most Americans individuals with permanent kidney failure. Medicare coverage meant that dialysis and kidney transplantation services would be covered as well as other medical services covered under the Medicare program.