ASN Responds to Medicare’s Proposed ESRD Program Changes

Mark Lukaszewski
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Every year the Centers for Medicare & Medicaid Services (CMS) releases its proposed rule for the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Quality Incentive Program (QIP). The American Society of Nephrology (ASN) Quality Metrics Task Force and Public Policy Board thoroughly assessed the proposed rule for potential effects on patient care and access to dialysis treatment before ASN submitted feedback to CMS.

Evaluating the quality of care patients receive, as well as their access to dialysis services and medications, are of the utmost importance in a bundled payment system. This article highlights ASN’s key recommendations to CMS outlined in the society’s recent comment letter.

Proposed adjustment to the ESRD PPS

ASN was pleased CMS codified the Protecting Access to Medicare Act of 2014 (PAMA) in the proposed rule, which will greatly mitigate the 10 percent cut to bundled payments Congress outlined in the American Taxpayer Relief Act. The PAMA provisions will help alleviate concerns raised by ASN and other stakeholders in the kidney community about the cut’s potential effects on patient access to high-quality care, particularly in rural and inner-city areas.

Eliminating barriers to home dialysis use

Deciding which dialysis modality to use for their treatment is one of the most important decisions a patient will make. This is why ASN supports efforts to 1) ensure patients have access to their preferred treatment modality, and 2) help remove barriers that could discourage patients from pursuing certain modalities, including home dialysis.

ASN has always agreed with CMS’ and Congress’ stated goal of increasing home dialysis utilization in the United States. However, ASN was disappointed that in the proposed rule, CMS states that modality choice does not constitute medical justification for paying for more frequent hemodialysis treatments. Given that approximately 10 percent of patients in the United States receive dialysis at home and less than 2 percent of patients receive home hemodialysis, ASN believes that CMS should not preclude modality choice as a medical justification for more frequent hemodialysis treatments, as it could potentially have material adverse effects on patients’ physical and emotional well-being.

ESRD QIP modifications

ASN provided CMS detailed guidance on the QIP and the proposed new, revised, or eliminated measures. The society emphasized that CMS should work transparently and collaboratively with the kidney community in measure development and specifications. Furthermore, ASN called for a conservative approach to the QIP and other grading systems. Specifically, CMS should focus on developing and implementing fewer measures that focus on the most meaningful items for patient care, rather than diluting the QIP and distracting dialysis providers with numerous measures of less substantial importance.

Pharmaceuticals and clarifying third-party medication distribution

Some pharmacies that distribute Medicare Part D medications have been inappropriately refusing to cover certain oral medications that are not prescribed for the treatment of renal dialysis services.

Currently, only medications directly related and essential to the provision of renal dialysis services should be paid for under the ESRD PPS. However, some Part D plans have refused to cover these medications or have required a prior authorization (which can take hours or days) before authorizing dispensing of medically necessary drugs not related to ESRD care. This is particularly concerning for time-sensitive medications like antibiotics, the oral versions of which are most often used to treat respiratory, urinary tract, or other infections not related to dialysis. In some instances, patients have required hospitalization or sought treatment in emergency departments in order to receive medications unrelated to maintenance dialysis. This is a complex issue and ASN is dedicated to continue working with CMS to guarantee that patients have access to necessary medications.

Implementing a risk-standardized 30-day all-cause hospital readmissions measure

ASN has strongly supported a standardized readmission ratio (SRR) measure in concept, and believes it could be an important indicator of patient care. However, the society is unable to support the currently proposed measure and it continues to urge CMS to work collaboratively and transparently with stakeholders to develop the optimal SRR measure for inclusion in the QIP. One major area of concern is if a discharged patient is readmitted prior to being seen at the dialysis facility, the facility is penalized even though it would not have the opportunity to intervene to possibly prevent the readmission.

ASN also encouraged CMS to clarify how unsuccessful kidney transplants would be addressed in this measure in the 6 months following the transplant. If a patient experiences graft rejection, it should not be reflected on the dialysis facility. These incidents reflect the transplant (and transplant complications) and therefore these patients and readmissions should be excluded. ASN is hopeful that in the future a well-defined SRR measure could have a positive effect on patient outcomes and looks forward to working with others in the community in order to make sure the SRR measure is focused for dialysis care.

Final implementation

CMS will likely release the final rule in early November, and ASN—with other kidney community stakeholders—will continue to advocate to CMS and Congress until then. For more information about the ESRD PPS and QIP or to read ASN’s full comment letter, please visit ASN’s advocacy website at