[Congressional Record Volume 142, Number 135 (Thursday, September 26, 1996)]
[Extensions of Remarks]
[Page E1698]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




[[Page E1698]]



  REFORM OF MEDICARE INTRADIALYTIC PARENTERAL NUTRITION [IDPN] BENEFIT

                                 ______
                                 

                        HON. FORTNEY PETE STARK

                             of california

                    in the house of representatives

                     Wednesday, September 25, 1996

  Mr. STARK. Mr. Speaker, when a group pays too much for a product and 
thereby provides windfall profits for the provider of that product, 
there is an overwhelming temptation by that provider to oversell and 
overuse the product.
  That's what has happened in Medicare, where we pay grossly too much 
for a product called intradialytic parenteral nutrition [IDPN]. As a 
result, kidney dialysis providers are sorely tempted to overprescribe 
and overuse this product. To stop the questionable use of this product, 
I am today introducing legislation to reform how Medicare pays for this 
nutritional treatment needed by a very small number of end stage renal 
disease patients.
  The current Medicare coverage of intradialytic parenteral nutrition 
[IDPN] has raised concerns involving the efficacy of this procedure as 
well as the possibility of gross overutilization. IDPN is the provision 
of parenteral nutrition that is administered during dialysis for end 
stage renal disease [ESRD] patients. IDPN is used to deliver nutrition, 
including amino acids, carbohydrates, and at times vitamins, trace 
elements, and lipids during dialysis. Although IDPN is provided in 
conjunction with dialysis, the coverage and reimbursement for IDPN are 
separate from the ESRD benefit. Specifically, coverage of IDPN is 
included under the prosthetic device benefit and reimbursed under the 
durable medical equipment benefit.
  Parenteral nutrition is covered for those patients who have a 
functional impairment of the gastrointestinal tract, which prevents 
sufficient absorption of nutrients to maintain an appropriate level of 
strength and weight. Enteral feeding, additional nutrition administered 
orally or through a tube and absorbed through a functioning 
gastrointestinal tract, must first be proven ineffective before 
parenteral nutrition will be reimbursed. Parenteral nutrition is 
prohibited when it merely serves to supplement regular feeding.
  There is concern within the medical field that IDPN is being 
unnecessarily utilized. Admittedly, there exist patients for whom IDPN 
is appropriate. According to a May 1993 Health and Human Service Office 
of Inspector General [OIG] report, an average of 2.4 percent of 
patients in dialysis facilities receive IDPN, in all cases only three 
times a week through their dialysis shunt. For-profit dialysis 
facilities had 2.9 percent of their ESRD patients using IDPN whereas 
only 1.5 percent of not-for-profit ESRD patients were on IDPN. This 
discrepancy between for- and not-for-profit hospitals should alert us 
to the possibility of abuse on the part of for-profit dialysis centers.
  Current billing practices for IDPN have resulted in enormous 
overcharging for IDPN supplies. Some claim that Medicare is paying 
nearly 800 to 1,000 percent more than the provider's acquisition cost 
for IDPN supplies. Medicare allows $250 for one combination of total 
parenteral nutrition solution, but the actual price of these supplies 
is no more than a couple of dollars. With such inflated prices, it is 
no surprise that this specific Medicare part B benefit has been 
overutilized.
  According to the U.S. Renal Data System's 1996 report, Medicare 
outlays for IDPN use rose from $51.6 million in 1991, $68.7 million in 
1992, and to $78.1 million in 1993, but dropped off to $46.4 million in 
1994. This treatment is considered by many in the medical field to be 
only appropriate for a very limited, constant number of end stage renal 
disease patients. It is no coincidence that the DMERC's new guidelines 
requiring more stringent documentation of the need for IDPN occurred 
just before this most recent decline in Medicare IDPN expenditures.
  Since ESRD patients are on a dialysis machine three times each week 
for a limited time, the total amount of intradialytic nutrition 
delivered is rather limited. It is estimated that only 10 to 20 percent 
of the recommended weekly calories for an ESRD patient are supplied 
using the IDPN delivery method. However, on average it cost $60,000 per 
year to administer these few calories. Only 70 percent of the amino 
acids administered through IDPN are retained within the body. This 
method of amino acid supplementation provides roughly 108 to 114 grams 
of protein per week. For comparison, an oral supplement given three 
times per day would provide 189 grams of protein per week. The cost of 
such enteral amino acid feeding is roughly $6.30 a week at the Portland 
VA Medical Center. With these kinds of gross windfall profits, there 
will be constant pressure to overutilize and abuse IDPN. It is up to us 
to legislate reimbursement reform.
  If the utilization rate and Medicare outlay increases were for a 
procedure that enjoyed definitive support from the medical community, I 
would not only justify but encourage widespread use of such treatment 
for our seniors and disabled. However, in the opinion of the HHS's own 
Office of Inspector General, ``the benefits of parenteral nutrition for 
ESRD patients are unproven, its use is associated with a high rate of 
complication, and the cost of care is disproportionate to the resources 
expended.''
  Clinicians disagree as to the efficacy of this treatment method. Some 
cite increasing nutritional parameters as evidence that IDPN is indeed 
nourishing the patient, while others feel that the relatively few 
studies showing a positive correlation between IDPN use and increasing 
nutritional parameters contains shortcomings in the design of the study 
leading to unreliable conclusions. Still others claim that these 
studies simply fail to demonstrate a link between decreasing morbidity 
and increasing nutritional parameters.
  We must address the IDPN pricing issue immediately to prevent the 
incentives for overutilization and the further plundering of our 
already endangered Medicare. I propose that we begin by first changing 
the reimbursement of IDPN from a rate within the durable medical 
equipment benefit to an incremental add-on payment within the ESRD 
benefit that would reflect the marginal costs of providing the 
individual components of an IDPN solution. This new ESRD benefit would 
cover only the arms length acquisition costs of the IDPN supplies plus 
an appropriate administrative service fee. The Secretary must conduct a 
survey of the IDPN market to determine the estimated true acquisition 
cost. To eliminate the benefit altogether would deny those few patients 
the right to a treatment that is indeed warranted. However, by altering 
the reimbursement of this treatment we will reduce the financial 
incentive for overutilization. In addition, specific HCPCS codes for 
IDPN will be created so as to be able to accurately identify the 
content of the solutions that are being administered.
  IDPN coverage has created a complex, confusing system with tremendous 
opportunity for abuse. I urge my colleagues to support this measure 
designed to create a simpler, more cost-effective means of covering 
intradialytic parenteral nutrition in end stage renal disease patients.

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