The Centers for Medicare & Medicaid Services used the rulemaking process last week to bring payment for acute kidney injury into the bundled payment system for dialysis care, making the therapy officially reimbursable in an outpatient setting.

While verifying the payment formula for AKI patients in an outpatient setting, CMS issued a request for a new dialogue: should these patients be subjected to meeting the quality measures––and performance scores––of the Quality Incentive Program?

New source of patients

The agency released its proposed rule on June 29 for changes to both the Medicare bundled payment and the Quality Incentive Program for 2018. Although the agency had released regulations and guidance for treating AKI patients in the outpatient setting prior to the law taking effect in January, it needed to address payment for AKI patients. For CY 2018, the proposed AKI base rate is $233.31, the same for patients diagnosed with end-stage renal disease.

Thus, with a somewhat “standardized” approach to payment rules, CMS says it believes AKI patients might also face the same rules for evaluating quality as typical dialysis patients.

“As a result of this change in the law, we believe that we now have authority to include this population in the measures we use for the ESRD QIP,” CMS wrote in the proposed rule. “We believe that it is vitally important to monitor and measure the quality of care AKI patients receive. We are seeking comment in this proposed rule on whether and how to adapt any of our current measures to include this population. We are also seeking comment on the types of measures that might be appropriate for future inclusion in the program that would address the unique needs of beneficiaries with AKI.”

Impact of social risk factors on quality

CMS is also seeking comments on including social risk factors when evaluating the quality of care via the QIP. Such social factors could include dual eligibility/low-income subsidy, race and ethnicity, and geographic areas of residence, CMS said. Such factors could be used to stratify measure scores and/or potential risk adjustment of a particular measure

Changes in composite rate payments, 2015-2018

CY Year                                  Payment Rate              $ Change/Treatment

2015                                              $239.39

2016                                              $230.39                                   -$9.00

Total bundled payments: + 0.2% compared with CY 2015

2017                                              $231.55                                   +$1.16

Total bundled payments: + 0.7% (freestanding), +0.9% (hospital) compared with CY 2016

2018 (proposed)                         $233.31                                 +$1.76

Total bundled payments: + 0.8% (freestanding), +1.0% (hospital) compared with CY 2017

CMS is also proposing other changes for the QIP, including:

Beginning in payment year 2019, the agency would shorten the Performance Score Certificates (PSCs), which dialysis facilities must post, to make the document simpler and easier to understand for patients.

Beginning in payment year 2020, change the ESRD QIP Extraordinary Circumstances Exception (ECE) policy to better align with the ECE policy adopted by other CMS Medicare quality programs. CMS would:

  • require that the facility submit the ECE form within 90 days following the event
  • allow an exception if there is an unresolved issue with a CMS data system which affected the ability of the facility to submit data.

The facility would not need to be closed to request an ECE exception, as long as the facility could show that its normal business operations were significantly affected due to an extraordinary circumstance beyond the control of the facility, CMS proposes.

Beginning in payment year 2021, CMS would remove the current Vascular Access Type clinical measures and replace them with new measures––Standard Fistula Rate and Long-Term Catheter Rate—that were recently endorsed by the National Quality Forum. CMS proposes to use CROWNWeb, rather than Medicare claims data, as the primary data source for these new measures. The agency would also revise the Standardized Transfusion Ratio clinical measure so that the specifications for that measure are consistent with the specifications that were endorsed by the National Quality Forum.

The 134-page proposed rule can be downloaded from the Federal Register here. The deadline for submitting comments on the rule is Aug. 28, and can be submitted at