Proposed Cuts to ESRD Program: ASN Responds

A proposal to cut the End-Stage Renal Disease (ESRD) Program by nearly 10 percent may have unintended consequences for people on dialysis. This was ASN’s key message to the Centers for Medicare & Medicaid Services (CMS) in comments on the proposed rule regarding the Medicare ESRD Prospective Payment System (PPS) and Quality Incentive Program (QIP).

ASN’s Quality Metrics Task Force, Public Policy Board, and Dialysis Advisory Group assessed the proposed rule to determine what effects it could have on patient care and access to dialysis before the society submitted feedback to CMS.

Previous ASN comment letters have focused on the quality portion of the proposed rule instead of the payment component. But given the magnitude of the proposed cuts, ASN leadership felt strongly that the society should focus on both sections of the rule, highlighting the effect the potential cuts could have on patient access to care. This article summarizes ASN’s main recommendations to CMS (Table 1).


This year Congress directed CMS to reexamine the ESRD base rate based on changes in drug utilization. In response to this mandate CMS proposed to decrease total payments to ESRD dialysis facilities by 9.4 percent. ASN is concerned about the potential serious adverse effects on the quality of care and patient access to dialysis that the proposed reduction in payment for ESRD services would have, especially if implemented at once.

“It’s troubling that Congress mandated a payment reduction at the same time that CMS is using the ESRD program as a model for bundled payment, a quality-incentive program, and a specialty-specific integrated care delivery model,” noted Thomas H. Hostetter, MD, chair of the ASN Public Policy Board. “The kidney community is working diligently on achieving the goals of the Quality Incentive Program (QIP), which was also mandated by Congress and implemented by CMS, in order to avoid further cuts in reimbursement.”

According to a 2012 Medicare Payment Advisory Commission report, the two largest dialysis providers saw Medicare margins of 3.4 percent on nearly 70 percent of spending, compared with 0.1 percent for 31 percent of spending for all other providers. In 2010, rural facilities operated on a –3.7 percent Medicare margin. This suggests many dialysis facilities risk closing, especially in rural and urban areas where few are covered by commercial insurers.

If any substantial base rate reductions occur, ASN strongly recommends cuts are phased in over several years, which would allow CMS to monitor for adverse effects on dialysis patients’ access and quality of care before implementation of further reductions.

CMS also recommended a “holdback” policy for home dialysis training, in which dialysis facilities would not be reimbursed for training patients who are unsuccessful in transitioning to home dialysis. ASN strongly recommended CMS eliminate this proposed policy. The society is concerned that the proposal would discourage attempts at home dialysis dissemination to more infirm individuals, who, if they are able to successfully perform home dialysis, may derive greater benefits. Moreover, the holdback appears to conflict with CMS’ stated goal of using the PPS as a mechanism to promote increased home dialysis utilization.

Evaluating quality of care as well as patient access to dialysis services and medications is of utmost importance within a bundled payment system, and is especially necessary in light of proposed changes to the base rate. Nonetheless, given the limited scientific evidence currently available regarding what comprises optimal care for patients on dialysis, the society expressed reservations about some aspects of the proposed modifications to the QIP program.

ASN noted existing and proposed QIP measures are not as relevant as others. Some are focused on processes—monitoring and collecting data—rather than on outcomes. Ample evidence shows most providers meet or exceed quality standards for several measures, such as hemoglobin. ASN plans to work with stakeholders and CMS to strengthen the QIP and expand the evidence base for meaningful new measures.

The proposed clinical hypercalcemia measure was of greatest concern. CMS would penalize facilities if a percentage of patients don’t meet the serum calcium target of 10.2 mg/dL or below. However, ASN believes there is insufficient scientific evidence to substantiate this target. No hypercalcemia performance gap currently exists and calcium management is the care standard. ASN recommended CMS not finalize the hypercalcemia measure, stating that it would create a reporting burden without benefiting patients.

CMS will likely release a final rule in early November, and ASN, with other kidney stakeholders, will continue to advocate to CMS and Congress until then. “More than 20 million Americans have kidney disease, and the Medicare ESRD program provides lifesaving care to nearly 400,000 beneficiaries with kidney failure,” said ASN President Bruce A. Molitoris, MD, FASN. “People with kidney disease, among the most vulnerable patients, are disproportionately underrepresented minorities, and such a large cut may reduce access to care and quality of treatment. ASN, the kidney community, and CMS must work together to provide the highest quality care possible to the millions of Americans with kidney disease, including those on dialysis whose lives are saved daily by the Medicare ESRD Program.” ASN’s comment letter is available at