The surprising victory in the presidential race for billionaire Donald Trump and a majority vote in the U.S. House and the Senate has clearly put current health care policy on borrowed time. Can any of these changes coming down the road in 2017 impact the ESRD program? We asked Robert Blaser, Director of Public Policy for the Renal Physicians Association, and Donna Bednarski, RN, MSN, ANP-BC, CNN, who is the American Nephrology Nurses Association’s Kidney Care Partners consultant, to help us sort through the impact of the shift in power on Capitol Hill.

 

NN&I: How did a flamboyant billionaire leap-frog over the likes of Marco Rubio, Jeb Bush, Ted Cruz, and other candidates to obtain the Republican nomination – and then, win the presidency.

Robert Blaser: Well, this is an issue that people are going to write volumes on in the future, but I’ll try and capture some high points in a few sentences.

First, whether you like what Mr. Trump is communicating or not, the man is a master communicator—his ability to get the upper hand in the Republican nomination process by dismissing his opponents with bumper-sticker epithets bordered on genius.

Secondly, he figured out a successful way to tap into a vein of dissatisfaction with career politicians in a way that others have failed to achieve (and this applied in both the primary and general elections).

Third, he ran in the general election against a candidate roughly as unpopular as he was, recalling that both parties felt that if they had nominated someone other than who they did, that they would have won in November in a cakewalk.

Finally, the complete and utter failure of the polling community almost certainly gave the Clinton campaign a false sense of security, leading them to rely on databases rather than shoe-leather campaigning in the heartland, and so to measure the White House drapes prematurely. As an aside, while my belief is that Mr. Trump won fair and square according to our electoral system, I’d point out that Mrs. Clinton does appear to have won the popular vote by approximately 2.5 million votes, about five times the margin that Al Gore won the popular vote over President Bush. The point being that if the Trump Administration thinks it has a massive governing mandate, that would be self-delusional and would contribute to him being a one-term president if that were to occur.

NN&I: Is there any concern about Trump’s victory and the ongoing expansion of nurse practice acts? Will they increase on their own?

Donna Bednarski, RN, MSN, ANP-BC, CNN: Nursing requires specialized knowledge and a skill base and every nursing role requires independent decision making. There are wide variations in nursing practice which differ based on the practice setting and patient population. However, nurse practice acts are controlled by state governments. All states have a nurse practice act which is enacted by each individual state legislature; as you can imagine there are variations in each state. Based on individual state control, Trump’s victory should not impact nurse practice acts.

NN&I: Let’s do a quick synopsis on some of the legislative and regulatory victories for the field of nephrology.

RB: The end of the year saw passage of the 21st Century Cures Act, which increases funding for the National Institutes of Health and deregulates a lot of U.S. Food and Drug Administration drug approval processes. This was a bipartisan bill that sailed through both chambers of Congress and had the support of the Obama Administration all the way, so we might want to take a picture of this one, so to speak. The bill provided a legislative vehicle for other health policy initiatives, and as part of this process the ESRD Choice Act, which allows prevalent ESRD patients to choose Medicare Advantage plans for their health insurance, was included.

Of course, MACRA implement-ation begins, which will restructure physician reimbursement and quality reporting for at least the next decade. Despite the release of a proposed rule that was more complex by orders of magnitude than anything ever seen in Medicare policy circles, the final MACRA rule took major steps to simplify CMS’ original proposals (the Agency really did a remarkable job of listening to the physician community), and will facilitate the ability all of physician practices (especially small and medium size practices) to survive and possibly even thrive. And while there are those that hope that the likely repeal of Obamacare will somehow provide relief from MACRA Quality Payment Program (QPP) requirements, I’d say no dice. MACRA (the Medicare Access and CHIP Reauthorization Act, which repealed use of the flawed sustainable growth rate—SGR—system) is a separate law that passed by large bipartisan margins, so while acknowledging the likely unpredictability of a Trump Administration, it seems certain to be here to stay.

Finally, the ESRD Prospective Payment System (PPS) rule included rulemaking for the first time providing coverage for care provided to Medicare beneficiaries with acute kidney injury (AKI) in outpatient dialysis facilities. CMS is required by law to pay the PPS rate (about $240) for the sessions, and did not put a limit on the number of sessions that will pay for, but gave every signal that utilization will be highly scrutinized.

NN&I: Donna, what new laws or programs are important to nephrology nurses?

DB: We are pleased with the passage of the 21st Century Chronic Cures Act which would allow Medicare beneficiaries with ESRD to enroll in Medicare Advantage (MA) plans. This allows more choice of benefits for our patients, including reduced cost sharing and care coordination that MA plans provide. We are also looking forward to the Senate Committee on Finance Chronic Care Working Group who is expected to revise their chronic care legislation and expected to reintroduce it in 2017.

We continue to support Title VIII, Nursing Workforce Development programs. These programs support the supply and use of qualified nurses to meet the needs of patients across the nation. Title VIII programs support nursing education at all levels, including support to institutions that educate nurses for practice in rural and medically underserved communities.

We also support the National Institute of Nursing Research which funds research to support evidence-based nursing practice. In addition, we support training programs to develop nurse scientists.

NN&I: What is the likelihood that we will see passage of legislation or new regulations in 2017 related to ESRD?

RB: On the legislative side, the control of the White House and both chambers of Congress by one party seems certain to generally grease the wheels of progress for legislation moving, but whether ESRD-specific legislation moves is another story. Some of the reason for this has nothing to do with ESRD, as there is a new Chair of the House Energy and Commerce Committee (Greg Walden, R-OR) and a relatively new Chair of the Ways and Means Committee (Kevin Brady, R-TX), plus new subcommittee chairs, so they’ll all have to get their legs under themselves a bit. Plus, the Republicans will be working on Obamacare repeal (for sure) and replace (eventually) at least at the onset of the 115th Congress, and then the major federal funding issues in the spring, so the focus may be on macro-level concerns for a while. Specific to ESRD initiatives, the issues of bandwidth of the Congressional attention span to include focus on kidney legislation, as well as kidney community unity behind any one issue, may slow progress in that regard.

In the regulatory arena, there’s policy making every year now that the ESRD Prospective Payment System (PPS) exists to update ESRD facility payment each year, and as noted previously the chances of revision to AKI coverage policy would seem to be good. Otherwise it seems like CMS rulemaking on third party payer issues could be imminent, but that has been the case.

However, all of this depends on how activist (or probably more appropriately, not) the new CMS is under HHS nominee Tom Price, MD, as it pertains to regulatory policy. To the extent that there are sweeping new policies, it would stand to reason that they would be in the direction of deregulation. Rep. Price is a physician who lobbied hard against the regulatory hassles presented by meaningful use and other CMS physician incentive programs, and is said to be skeptical of the value-based purchasing orientation in which CMS is currently so heavily invested. Thus, it will be instructive to see how committed he may be to unraveling some of these programs, and if so, whether the bureaucracy is so entrenched that he has difficulty doing so.

DB: The immediate focus of the 2017 legislative agenda will likely be on the Affordable Care Act (ACA). Although the focus may be through budget reconciliation for repeal, consideration may be given for a replacement plan to the ACA which would take longer and require a delay. Medicaid reform could also be part of the replacement plan. Dialysis is not a mandatory Medicaid benefit, so this must be watched closely for the risk of losing it as a paid benefit.

 

NN&I: Rob, give us the final verdict on the Physician Fee Schedule for 2017. Will nephrologists lose money for each patient visit?

RB: No, nephrologists shouldn’t lose money on patient visits; the RVUs for all the dialysis codes remained stable, and the conversion factor (the multiplier used to determine Part B payment) went up a hair. Of course, the interventional dialysis codes underwent substantial revision and reduction, and to the extent that nephrology practices are heavily invested in interventional dialysis services, money will be lost there. It is worth noting that the CMS specialty-specific impact chart for 2017, based on the theoretical application of 2017 payment policies on previous years’ claims data, showed nephrology having a zero percent impact.

 

NN&I: Lots of discussion about the new AKI allowance––CMS will now pay for treating such patients in an outpatient setting. Do you think this will benefit both patient and provider?

RB: There are of course many details to be worked out on AKI care delivery at the point of contact, but yes, it would potentially seem to be of benefit to both patients and providers. Patients should be able to receive care in a more convenient manner at a facility closer to their home if applicable, and some of the hassle and uncertainty of providing AKI care should be relieved for providers. Of course, this is Medicare so it bears watching.

DB: I believe it allows providers an opportunity to have their patients cared for in the setting appropriate to meet patient needs. Many hospitals are not prepared to meet the requirements for dialysis services for AKI patients and therefore not an appropriate setting for them.

NN&I: Because of the Trump victory and a sense of plans to “drain the swamp,” will ESRD still have some important friends in the halls of the Congress? We have seen some retirements this year. Who would the industry’s supporters be?

RB: Rep. Jim McDermott (D-WA), longtime friend of the kidney community and Co-Chair of the Congressional Kidney Caucus is a great loss. Rep. McDermott unfailingly mentioned Belding Scribner whenever he addressed a kidney group; I highly doubt any other legislator knows who Belding Scribner is. That’s probably the biggest departure of note, there were some other changes where a legislator moved from the House to the Senate or otherwise had a change of status within Congress but there are no departures of profound meaning in my opinion. Reps. Joe Pitts (R-PA, Chair of the Energy and Commerce Health Subcommittee, who retired), and Xavier Becerra (D-CA, key member of the Ways and Means Committee who left to become the Attorney General of California) were both somewhat engaged in kidney disease, but certainly not to the extent of Rep. McDermott.