Innovative ESRD Care and Payment Models: CMS Seeks Input

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A request from the Centers for Medicare & Medicaid Services (CMS) for input on new care and payment models has ASN gearing up to weigh in on what could be significant changes in the way that Medicare treats kidney disease.

The CMS request came in its annual proposed updates of policies and payments related to renal disease. Published on June 24, 2016, other noteworthy parts of the updates include permitting acute kidney injury (AKI) patients to be treated in end stage renal disease (ESRD) clinics, introducing equivalency payments for more frequent dialysis treatment, and offering higher payment for home dialysis training.

The provision that has many in ASN excited is on page 204 of the 260-page proposed rule, where CMS “seeks input on innovative approaches to care delivery and financing for [Medicare] beneficiaries with end stage renal disease. This input could include ideas related to innovations that would go above and beyond the Comprehensive ESRD Care (CEC) Model with regard to financial incentives, population or providers engaged, or the scale of changes, among other topics.”

CMS requests responses to 10 questions covering a broad range of issues, including how providers who participate in alternative payment models could:

coordinate care for beneficiaries with chronic kidney disease (CKD) and improve their transition to dialysis;

target key interventions for beneficiaries at different stages of CKD;

promote increased rates of renal transplantation;

help reduce disparities in rates of serious kidney disease and adverse outcomes among minority groups; and

facilitate changes in care delivery to improve patient quality of life.

“ASN is thrilled that CMS is seeking input to develop and refine innovative payment models in the kidney space,” said ASN President Raymond C. Harris. “We are particularly enthused about the possibility of expanding beyond the focus on dialysis to potentially include CKD and transplant care. The society strongly supports more integrated care for kidney patients across the spectrum of kidney disease, and looks forward to providing input to CMS and encouraging the agency to explore truly comprehensive models ranging from CKD through transplant and end of life.”

Rachel Meyer, associate director of policy and government affairs, said that ASN is already promoting the need for these kinds of innovations. ASN included the outline of a comprehensive model for care of CKD in a letter it sent to CMS on June 27, 2016, detailing its comments on the agency’s proposals for implementing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). That law ended the Sustainable Growth Rate formula for determining Medicare payments to providers and was designed to create a framework for rewarding providers for supplying better care rather than more care.

AKI treatment in ESRD facilities

Another potentially significant change proposed in the rules is that Medicare and Medicaid patients with AKI will be able to receive dialysis services in ESRD facilities beginning next year. CMS will provide payment based on the ESRD prospective payment rate, as adjusted by the wage index. However, CMS said in a press release 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.”

ASN will certainly seek to influence the shape of this new program, said John R. Sedor, chair of the ASN Public Policy Board: “As CMS begins to implement this new law, it will be tremendously important for them to take into account the many ways in which patients with AKI are unique from patients with ESRD. Their care will need to reflect those differences, and be reimbursed accordingly. On the quality front, what constitutes optimal care for patients with ESRD is often not even appropriate care for patients with AKI, so keeping the new AKI patients out of quality reporting systems such as the Quality Incentive Program is vital. At the same time, we need better data to inform what exactly optimal AKI care looks like.”

This change in coverage of AKI was mandated by a provision tucked into the Trade Preference Extension Act of 2015. Although AKI care would seem to have nothing to do with international trade, the provision was probably included as a budget offset to save money and keep the trade bill budget neutral.

Change in payments for more treatments

CMS is also proposing a change in the payment system when an ESRD facility provides a patient with more than three hemodialysis treatments per week, which is often the case for hemodialysis patients who are dialyzing in their homes. Payment is generally capped at three dialysis sessions per week, with more sessions reimbursable if they are deemed medically necessary by a physician, such as in the case of congestive heart failure or pregnancy.

The proposed rule’s intent is to “provide a mechanism for payment for evolving technologies that provide for a different schedule of treatments that accommodate a patient’s preference and thereby improve that patient’s quality of life,” and it notes that more frequent dialysis allows for shorter treatments, affording patients greater flexibility in managing their illness. CMS seems to justify the capped payment proposal by noting that the same level of toxin clearance can be achieved in three treatments, and “there is a lack of objective data to justify additional payment for HD treatments beyond three treatments per week.”

However, CMS notes that ESRD facilities have expressed concern that because of the limit, they are not able to report additional treatments on their monthly claim forms and are not paid for each treatment. To encourage facilities to report all treatments, CMS is proposing a payment equivalency formula for these treatments similar to the one used in peritoneal home dialysis, in which patients receive more than thrice weekly treatment sessions, but the total payment is capped.

CMS proposes to “calculate a per treatment payment amount that would be based upon the amount of treatments prescribed by the physician” regardless of how many actual treatments the patient receives. Thus, the equivalency payment would be based on three treatments a week. Because allowing more bills would represent “a substantial change for the ESRD facility’s billing systems and for the Medicare Administrative Contractor,” the change would not be fully implemented until July 1, 2017.

Home dialysis training increase

The proposed rule also contains a provision that could improve the climate for home dialysis by paying more for training. CMS proposes to increase the number of reimbursable hours for training for a registered nurse for home dialysis and self-dialysis teaching from 1.5 hours or $50.16, to 2.7 hours, to $95.57. (CMS assumes that the hourly wage for a nurse providing dialysis training in 2017 will be $35.93.)

Little change in prospective payment

Although the updates contain some big changes in other areas, it’s pretty much the status quo when it comes to the base bundled payment rate for renal dialysis services to treat ESRD in Medicare beneficiaries. CMS proposes increasing it by 65 cents, from this year’s $230.39 to $231.04 in calendar year 2017.

Quality Incentive Program

Under the ESRD Quality Incentive Program (QIP), facilities that fail to achieve a minimum score on quality measures face a reduction in their payment rates of up to 2%. The new rule does not propose any changes in quality measures for next year, but does propose changes for 2018, 2019, and 2020.

For 2018, for example, CMS proposes two changes to the hypercalcemia clinical measure. The changes involve including plasma as an acceptable substrate in addition to serum for calcium and a technical change to the denominator definition to account for periods during which a facility reports no calcium values.

The proposed QIP for 2019 adds a new Safety Measure Domain, so it includes seven clinical/outcome measures and five to six reporting measures, a large increase from the two to three measures in the early years of the QIP, according to Daniel E. Weiner, chair of the ASN Quality Metrics Task Force. “The struggle for CMS and the community is trying to find reliable measures that evaluate truly important aspects of dialysis patient care,” Weiner said. “This is very difficult when clinical trials lack dialysis data to support any of the currently existing measures, not to mention any measures that may be proposed in the future. Ironically, this lack of evidence seems to have led to more measures being applied to the QIP, a trend that runs the risk of diluting the impact of high performance on measures that may be more important and better supported, such as the vascular access measures. Ultimately, the ideal QIP is both more parsimonious, containing fewer measures, as well as more important, containing the measures that, if achieved, are most likely to make meaningful differences in patients’ lives.”