Telehealth services for home dialysis patients and care for patients with acute kidney injury (AKI) will get a boost from changes to the Physician Fee Schedule and the End-Stage Renal Disease (ERSD) Prospective Payment System (PPS) announced by the Centers for Medicare & Medicaid Services (CMS) in October and November.
The changes, which go into effect in 2017, are part of an ongoing effort by the agency to improve care quality while lowering costs by changing the way care is delivered and clinicians are paid, according to the agency. The changes expand access to outpatient dialysis for patients with acute kidney injury (AKI), encourage telehealth consultations for home dialysis education and advanced care planning, and will allow patients to choose having their nephrologist lead their care.
The new Physicians Fee Schedule will let patients designate their nephrologist as their primary care provider. This allows them to avoid additional visits to a primary care physician on top of coming to a dialysis center three times a week or doing daily home dialysis, said Rajnish Mehrotra, MD, MS, a professor at the University of Washington and nephrology section chief at Harborview Medical Center in Seattle.
“It will be better for patients,” Mehrotra said. “Even nephrologists sometimes lose sight of the enormous burden that the treatment of ERSD places on patients.”
It may also allow nephrologists more time to provide high quality care. For example, Mehrotra noted managing high blood pressure or diabetes requires time for patient education and a good relationship between the patient and the health care team.
It also lays the groundwork for the development of new payment models that will reward nephrologists for coordinating the care of their patients.
“Clearly, this is an area that needs further exploration in demonstration projects, but it seems to be a reasonable first step in recognizing the care that many nephrology practices are already providing,” said Daniel Weiner, MD, MS, associate professor of medicine at Tufts University in Boston.
Acute kidney injury
Perhaps the biggest change for nephrologists is that patients with AKI will now be able to receive dialysis from outpatient centers that serve patients with ERSD. Previously, patients with AKI had to receive dialysis through a hospital, which could be far from home, explained Mehrotra.
“Now, they can go to the dialysis unit in their community,” Mehrotra said.
They also will no longer miss out on the specialized chronic disease care, including social work and dietary advice, that ERSD centers provide, Weiner said.
Services that are needed for patients with AKI, including drugs and lab tests, that are not currently covered as part of the ERSD bundle will be reimbursed by CMS. Weiner stated, however, that there are still some questions about how tests and interventions included in the bundle will be reimbursed. For example, he noted that he would more frequently check kidney function labs, urine clearance, and electrolytes in patients with AKI than in patients with ERSD. There are also questions about when patients who don’t recover from AKI should be designated as having ERSD.
Overall, the changes are an improvement, Weiner said.
“There remains a lot of work to be done here, including review of payment adequacy, clinical monitoring, and clinical outcomes,” he said. “Hopefully, this year’s PPS rule will be the first step in an iterative process that will mature over time.”
Telemedicine
The rules also boost reimbursement for telehealth services for patients with chronic kidney disease.
Payments for home dialysis training were doubled to $95.60 under the ERSD program. The Physician Fee Schedule also extended coverage for telehealth services for patients receiving dialysis at home and for advanced care planning. Such services avoid unnecessary patient trips to a facility and may increase the likelihood of patients getting care, Methrotra noted. They also afford patients more privacy than might be possible at a dialysis center for delicate discussions about sensitive issues like end-of-life care, he said.
“Many patients select home dialysis due to logistic considerations that make visiting centers challenging,” said Weiner. “A lot more work is needed to explore how to best incorporate telehealth into dialysis and other nephrology care, but this expanded coverage is a necessary first step.”
