• 1.

    Delgado C, et al. A unifying approach for GFR estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease. J Am Soc Nephrol 2021; 32:29943015. doi: 10.1681/ASN.2021070988

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    Organ Procurement & Transplantation Network (OPTN). OPTN board approves elimination of race-based calculation for transplant candidate listing. June 28, 2022. https://optn.transplant.hrsa.gov/news/optn-board-approves-elimination-of-race-based-calculation-for-transplant-candidate-listing/

    • Search Google Scholar
    • Export Citation

Recent ASN Advocacy Efforts in Transplantation, Dental Coverage, and Medicare Quality and Health Equity

Full access

Summer 2022 ushered in a whirlwind of regulatory activities that herald an array of changes underway in kidney health care. These changes represent a range of advocacy efforts undertaken by ASN and other members of the kidney community over the past decade.

Kidney transplantation

In June 2022, ASN and the National Kidney Foundation (NKF) continued their work together following the December 2021 publication in JASN of A Unifying Approach for GFR Estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease[s] (1), advocating with the Organ Procurement & Transplantation Network (OPTN) board of directors to pass a proposal to require transplant hospitals to use race-neutral calculations when estimating a patient's glomerular filtration rates for patients being considered for kidney transplantation. ASN and NKF also requested that the OPTN board address the use of race factors in the Kidney Donor Risk Index. On June 27, 2022, the OPTN board unanimously approved a measure to require transplant hospitals to use a race-neutral calculation when estimating a patient's level of kidney function (2).

Dental coverage for transplant candidates and recipients

Researchers have long demonstrated that “[O]ral health represents a potential determinant of health outcomes in patients with end-stage renal diseases (ESRD).” Studies show that adults with ESRD have more severe oral disease than the general population, which can lead to increased mortality. As a result, the Centers for Medicare & Medicaid Services (CMS) proposed that Medicare expand access to dental services for individuals seeking kidney transplant or receiving immunosuppressant medications in a physician fee schedule beginning in calendar year 2023.

ASN expressed its strong, ongoing support for this proposal in its comment letter to CMS, highlighting that access to dental services is important for dialysis patients as part of their ability to access kidney transplants, as well as being essential for accessing cardiovascular procedures for valvular disease, which is more common in dialysis patients. Specifically, ASN strongly encouraged CMS to finalize the following:

  • Clarify that payment can be made under Medicare Part A and Part B for dental services that are inextricably linked to and substantially related and integral to the clinical success of an otherwise covered medical service, including dental or oral examination, as part of a comprehensive work-up before a kidney transplant surgery, as well as clarify that payment can be made for services that are ancillary to these dental services, such as X-rays, administration of anesthesia, use of an operating room, and other facility services, regardless of whether the services are furnished in an inpatient or outpatient setting.

  • Expand payment under Medicare Parts A and B for dental services that are inextricably linked to and substantially related and integral to the clinical success of a certain covered medical service and are not subject to the exclusion under the Social Security Act, including the dental or oral examination, as part of a comprehensive work-up before an organ transplant, cardiac valve replacement, or valvuloplasty procedure, and expand necessary dental treatments and diagnostics to eliminate oral or dental infections found during a dental or oral examination as part of a comprehensive work-up before an organ transplant, as well as for services that are ancillary to these dental services, such as X-rays, administration of anesthesia, and use of the operating room, regardless of whether the services are furnished in an inpatient or outpatient setting.

  • Expand payment to include dental examinations and medically necessary diagnostic and treatment services before treatments that include initiation of immunosuppressant therapy.

Easing disparities and ensuring quality in the Medicare ESRD Program

CMS requested information on quality indicators for home dialysis in the proposed ESRD Prospective Payment System (PPS), Quality Incentive Program (QIP), and ESRD Treatment Choices (ETC) Model rule and highlighted the two general types of dialysis currently in use: hemodialysis (HD) and peritoneal dialysis (PD). CMS noted that although HD can be performed both in-center and at home (and PD can be furnished in both sites of care as well), for the purposes of the Request for Information (RFI) in the proposed rule, CMS considers PD to be exclusively a home modality.

Since 2020, the International Society for Peritoneal Dialysis has recommended that the adequacy of PD should no longer be determined by Kt/V (K, clearance; t, dialysis time; V, volume of distribution). Rather, home dialysis should be “goal directed” to promote high-quality dialysis care that helps patients meet their own individual care goals (e.g., remaining independent at home and maintaining a high quality of life). Given current treatment guidelines, an over-reliance on Kt/V as a quality measure for PD runs counter to the spirit of patient-reported outcome measures and thus, may encroach on patient-centered care.

ASN recommended that CMS reevaluate the assessment of Kt/V in PD by examining and tailoring the performance standards within the ESRD QIP separately for in-center HD and PD. Currently, the PD and HD performance standards for achievement threshold, median, and benchmark Kt/V in dialysis are the same regardless of modality, with a median performance standard of 97.61% estimated for program year 2025 (with an achievement threshold of 94.33% and benchmark of 99.42%). These standards are inappropriate for a substantial proportion of PD patients, as discussed in the current PD guidelines. ASN believes that achieving a target Kt/V should be disaggregated for PD and HD, with the application of different performance standards for PD. These can then be reaggregated at the facility level to comprise a revised Kt/V comprehensive measure that does not disadvantage patients electing for PD and facilities providing PD.

ASN urged CMS to convene a technical expert panel to evaluate the basic framework for these performance standards through the lens of clinical knowledge and intended to limit unintended consequences and individualize care, realizing that the proportion of patients at a facility who achieve a given Kt/V threshold for in-center HD typically will be higher than the proportion for PD. ASN also recommended prioritization of outcome measures to focus on relevant clinical outcomes, such as reporting peritonitis rate as the number of episodes per patient year, inpatient readmission rates, and mortality. Other types of metrics that ASN recommended that CMS review were patient-reported outcome measures and patient-reported experience measures as key home dialysis indicators.

CMS also asked an array of questions in the proposed rule in a section titled “Requesting comments on improving CMS's ability to detect and reduce health disparities for individuals receiving renal dialysis services.”

ASN recommended CMS consider a health equity incentive model, similar to the ETC Model, with a similarly structured incentive in which a payment adjustment is based on the percentage of patients who are dual eligible or with a low-income subsidy (to incentivize care of these patients). The model could include add-on payments for a higher percentage of dual-eligible home dialysis patients or patients with social challenges, such as housing and/or food insecurity. In response to the RFI, ASN discussed a number of comorbidities that should be examined when calculating case-mix adjustors, such as mental health diagnoses (e.g., depression related, bipolar disorder, anxiety, and substance abuse), language and communication barriers, physical disabilities (i.e., wheelchair dependency), and social determinants of health, including but not limited to housing and food insecurity.

ASN further endorsed accurate and standardized, self-identified demographic information (including information on race and ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, and language preference) for the purposes of reporting, stratifying data by population, and other data collection efforts that CMS believes would refine the ESRD PPS payment policy.

ASN also discussed the use of Z codes (used as reason codes to capture factors that influence health status and contact with health services) and how suppression of data from certain quality measures in the QIP would affect the rating results in 2023, as those ratings are based on data from 2021 and were heavily impacted by COVID-19.

References

  • 1.

    Delgado C, et al. A unifying approach for GFR estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease. J Am Soc Nephrol 2021; 32:29943015. doi: 10.1681/ASN.2021070988

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    Organ Procurement & Transplantation Network (OPTN). OPTN board approves elimination of race-based calculation for transplant candidate listing. June 28, 2022. https://optn.transplant.hrsa.gov/news/optn-board-approves-elimination-of-race-based-calculation-for-transplant-candidate-listing/

    • Search Google Scholar
    • Export Citation
Save