Clinics would see a small increase next year in payment for dialysis services under a proposed rule released by the Centers for Medicare & Medicaid Services on June 24. The rule also proposes new quality measures for Medicare’s Quality Incentive Program for the payment years 2018-2020.
“The ESRD PPS proposed rule is one of several rules for calendar year 2017 that reflect a broader administration-wide strategy to deliver better care at lower cost by finding better ways to deliver care, pay providers, and use information,” CMS said in a statement. “Provisions in these rules are helping to move our health care system to one that values quality over quantity and focuses on achieving better health outcomes, preventing disease, helping patients live successfully at home, helping manage and improve chronic diseases, and fostering a more efficient and coordinated health care system.”
The proposed rule also includes provisions for the treatment of acute kidney injury patients in outpatient dialysis clinics, a major legislative victory for the community in 2015. The new law, which takes effect in January, was passed after being tagged on to the Trade Preferences Extension Act of 2015.
Here is a summary of the proposed rule; click here for the complete Federal Register file
Prospective Payment System
There are several pieces to this payment formula. For 2017, CMS is proposing to:
- Change the bundled base rate for CY 2017 to $231.04. This reflects a reduced market basket increase (0.35%), application of the wage index budget-neutrality adjustment factor (0.999552), as well as the application of the home and self-dialysis training budget-neutrality adjustment factor (0.999729). The proposed CY 2017 ESRD PPS base rate is an increase of $0.65 from the CY 2016 base rate of $230.39.
CMS is not proposing any changes to the application of the wage index floor.
- CMS is proposing to update the outlier services fixed dollar loss amounts for adult and pediatric patients and Medicare Allowable Payments (MAP) for adult patients for CY 2017 using 2015 claims data. Based on the use of more current data, the fixed-dollar loss amount for pediatric beneficiaries would increase from $62.19 to $67.44 and the MAP amount would increase from $39.20 to $39.92, as compared to CY 2016 values. For adult beneficiaries, the fixed-dollar loss amount would decrease from $86.97 to $83.00 and the MAP amount would decrease from $50.81 to $47.26.
For hospital-based ESRD facilities, CMS projects an increase in total payments of 0.7%, while for freestanding facilities, the projected increase in total payments will be 0.5%.
The PPS and home dialysis
- CMS is proposing to increase the total number of hours of training by a registered nurse for peritoneal dialysis (PD) and hemodialysis (HD) that is accounted for by the home and self-dialysis training add-on payment adjustment. The current home and self-dialysis training add-on is $50.16, which reflects 1.5 hours of nurse training. CMS is proposing to calculate the increase based on the average treatment times and weights for each modality. We propose to use these as proxies for the total time spent by nurses training beneficiaries for home or self-dialysis, with the assumed hourly wage for a nurse providing dialysis training for 2017 being $35.93. Under this proposal, CMS would increase the hours of nurse training time to 2.66 hours, which would result in a home and self-dialysis training add-on payment adjustment of $95.57.
The budget for the ESRD Program overall continues to grow as patients show improved survival on dialysis. Under the ESRD PPS proposed for calendar year (CY) 2017, Medicare expects to pay approximately $9.0 billion to approximately 6,000 ESRD facilities for dialysis services.
Acute kidney injury care in freestanding facilities
- CMS will provide coverage and payment for renal dialysis services furnished on or after January 1 by an ESRD facility to an individual with AKI. Under the law, payment will be in the amount of the ESRD PPS base rate, as adjusted by the wage index. CMS is proposing that drugs, biologicals, laboratory services, and supplies furnished to beneficiaries with AKI that are not considered to be renal dialysis services but that are related to the dialysis as a result of their AKI would be separately payable.
Quality Incentive Program
PY (payment year) 2018: This ESRD QIP measure set, last updated as part of the CY 2016 ESRD PPS final rule, contains eight clinical measures and three reporting measures encompassing anemia management, dialysis adequacy, vascular access type, patient experience of care, infections, hospital readmissions, and mineral metabolism management.
The agency now proposes two substantive changes to the Hypercalcemia clinical measure to “ensure that the measure remains in alignment with the measure specifications endorsed by the National Quality Forum (NQF). These changes involve updating the measure’s technical specifications for PY 2018 and future years to include plasma as an acceptable substrate in addition to serum calcium, as well as changing the denominator definition to include patient-months in the denominator even in the event that a facility reported no calcium values during the three-month study period.”
FY 2019: The PY 2019 ESRD QIP measure set, also finalized in the CY 2016 ESRD PPS final rule, contains seven clinical measures and five reporting measures encompassing anemia management, dialysis adequacy, vascular access type, patient experience of care, infections, mineral metabolism management, safety, pain management, depression management, and hospital readmissions.
CMS proposes to create a new Safety Measure Domain as a third category of measures for PY 2019. To do so, CMS proposes to reintroduce the Expanded National Healthcare Safety Network (NHSN) Dialysis Event reporting measure into the ESRD QIP measure set for PY 2019 and to combine this measure with the existing NHSN Bloodstream Infection (BSI) clinical measure in a new NHSN BSI measure topic, which will be the only measure topic in this new Safety Measure Domain.
For PY 2019, CMS proposes to apportion 75% of a facility’s Total Performance Score to the Clinical Measure Domain, 15% to the proposed Safety Measure Domain, and 10% to the Reporting Measure Domain.
In addition to the clinical measures finalized for PY 2019, CMS proposes to:
- Add the Standardized Hospitalization Ratio (SHR) clinical measure.
- Adopt a new Ultrafiltration Rate reporting measure. CMS also proposes to replace the existing Mineral Metabolism reporting measure (calculated in part using claims data) with a new Serum Phosphorus reporting measure that uses CROWNWeb data.
FY 2020: The PY 2020 ESRD QIP measure set contains eight clinical measures and seven reporting measures encompassing anemia management, dialysis adequacy, vascular access type, patient experience of care, infections, mineral metabolism management, safety, pain management, depression management, and hospital readmissions.
CMS proposes to apportion 80% of a facility’s TPS to the Clinical Measure Domain, and 10% each to the Reporting Measure Domain and the Safety Measure Domain.
Comments on the proposed rule are due Aug. 23.