The American Society of Nephrology’s (ASN) Quality Committee has its hands full in 2018. First, the Quality Payment Program (QPP) created by the Medicare Access and CHIP Reauthorization Act (MACRA) enters its second year after a very limited implementation as a transition year in 2017. Foremost, the QPP is beginning to calculate a “cost” section in physician scores and will need to be monitored closely by ASN and other medical societies for unintended consequences. Equally important are efforts to include acute kidney injury (AKI) in the End-Stage Renal Disease Prospective Payment System and Quality Incentive Program (PPS/QIP) and increase access to the use of telehealth in the Physician Fee Schedule. Working with regulators on these three major rules will comprise a significant portion of the ASN Policy team’s work in 2018.
In general, three major Medicare rules that largely affect clinician reimbursement and nephrology practice are updated annually and primarily cover the QPP, PPS/QIP, and the Physician Fee Schedule. The ASN Quality Committee, chaired by Daniel E. Weiner, MD, FASN, reviews these rules every year. Medicare rules are issued as proposed first with a 60-day comment period followed by a later issuance of the final rule. The ASN Quality Committee annually provides comment on all three rules and meets with the Centers for Medicare & Medicaid Services (CMS) to provide input on various issues throughout the year.
Here are some of the highlights of these three rules for 2018.
The Quality Payment Program
Complex patient bonus. ASN has advocated for a recognition within the QPP of the challenges of dealing with complex patients. CMS adopted a complex patient bonus of 5 points. While ASN expressed support for the complex patient bonus, it will likely continue to lobby for a more robust bonus.
Costs. Costs in 2017, the first year of the QPP—declared a transition year by Medicare—had a weight of 0% to allow clinicians to adjust to the new system. For 2018, CMS decided to score costs at 10% believing the statutory 30% for 2019 was too big of an adjustment and did not allow enough time for clinicians to adjust to the calculations. CMS will not use episodes it has been designing for this calculation. Instead it will use Medicare Spending per Beneficiary (MSPB) and total per capita costs. This is a separate issue than the ESRD bundle.
Performance threshold. The 2017 transition year for the QPP performance threshold was three points, allowing clinicians to basically report one item and avoid any penalties for that year. CMS has raised the performance threshold to 15 for 2018. ASN advocated for 15 or less for this year and has cautioned CMS to move cautiously while implementing this major new program.
Other issues ASN supported that were adopted for the QPP in 2018 include:
• Allowing the use of 2014 Edition and/or 2015 Certified Electronic Health Record Technology (CEHRT) in 2018 for the Advancing Care Information performance category, and giving a bonus for using only 2015 CEHRT.
• Automatically weighting the Quality, Advancing Care Information, and Improvement Activities performance categories at 0% of the MIPS final score for clinicians impacted by Hurricanes Irma, Harvey, and Maria and other natural disasters.
• Adding 5 bonus points to the MIPS final scores of small practices.
• Adding Virtual Groups as a participation option for MIPS.
• Decreasing the number of doctors and clinicians required to participate to provide further flexibility by excluding individual MIPS eligible clinicians or groups with ≤ $90,000 in Part B allowed charges or ≤ 200 Medicare Part B beneficiaries.
The End-Stage Renal Disease Prospective Payment System and Quality Incentive Program (PPS/QIP)
The Prospective Payment System. The ESRD PPS provides additional payment for high cost outliers when there are unusual variations in the type or amount of medically necessary care. ASN has been encouraging CMS to revise the outlier payment structure such that only the exact necessary amount is withheld to meet payouts or reinvest the difference between actual outlier costs incurred and the funds withheld to support research and other patient-focused initiatives within CMS’ scope. CMS has been withholding more than it pays out for its outlier policy. CMS has not acted upon this, and ASN will continue to advocate for changes to this policy.
Patients with Acute Kidney Injury (AKI). ASN has repeatedly cautioned regulators to move very cautiously when considering including patients with AKI in the ESRD PPS/QIP. In the final rule for 2018, CMS acknowledged “that care for AKI patients is different from the care provided to individuals with ESRD.” CMS stressed the distinction in its policies stating, “To address the higher costs associated with AKI patients as compared to ESRD patients, we finalized a policy of paying for all AKI dialysis treatments provided to a patient, without applying the monthly treatment limits applicable under the ESRD PPS. We also finalized a policy to pay separately for all items and services that are not part of the ESRD PPS base rate.” CMS also will not apply the ESRD Network fee to the AKI dialysis payment rate.
ASN continues to advocate for permitting patients with AKI who do not recover kidney function and go on to receive a diagnosis of ESRD to have their first date of dialysis for AKI count as their first date of dialysis for purposes of transplant waitlisting.
ASN and other members of the kidney community are conducting further outreach to CMS to urge caution when including patients with AKI in the QIP and to only do so in close consultation with nephrologists.
Social Risk Factors in the QIP. CMS continues efforts to develop appropriate adjustors for social risk factors in the QIP to ensure equitable access to care for disadvantaged populations. It is continuing to consider the analyses and recommendations from the December 2016 report prepared by the Office of the Assistant Secretary for Planning and Evaluation, the January 2017 report released by the National Academies of Sciences, Engineering, and Medicine, and the ongoing evaluation work by the National Quality Forum (NQF).
The Physician Fee Schedule
Telehealth. Perhaps one of the most important new areas of coverage for nephrology, after new AKI coverage policies, is in the area of telehealth. In comments to CMS, ASN has affirmed the clinical safety and feasibility of assessing vascular access sites via telehealth technologies. While CMS said it did not believe it had sufficient evidence to make this change for the 2018 rule, it did declare “[W]e are interested in more information about current clinically accepted care practices and to what extent telecommunications technology can be used to examine the access site.” ASN is working with CMS to identify the evidence CMS feels it needs to make this change.
ASN is also advocating for adding living donor evaluation, transplant recipient evaluation, and transplant-related follow-up care to the list of telehealth-eligible services.
Evaluation and Management Codes and Chronic Care Management Codes. ASN is urging CMS to reform existing Evaluation and Management coding and documentation guidelines to better align them with the current practice of medicine, reduce the associated burden on healthcare professionals, and refocus efforts on patient care. The society also urges CMS to strengthen access to the chronic care management codes by permitting people with ESRD to access this benefit.
