This afternoon, the Centers for Medicare and Medicaid Services released its CY 2018 End Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals with Acute Kidney Injury, and End-Stage Renal Disease Quality Incentive Program proposed rule. Besides setting a slightly increased end stage renal disease (ESRD) prospective payment system (PPS) base rate and making minor changes to the ESRD Quality Incentive Program (QIP), the rule is notable in that it does not include changes to the durable medical equipment (DME) fee schedule or competitive bidding program, as it has in past years. In addition, the proposed rule is unique as it establishes a request for information (RFI) on public suggestions for ways to make the Medicare program more flexible, efficient, and patient-centered.
CMS stated that this rule is part of a broader strategy to relieve burdens on providers; support the doctor-patient relationship; and promote transparency, flexibility, and innovation. Administrator Seema Verma believes that its focus on patient-centered care “allows providers to direct their time and resources to improving health outcomes for all patients rather than complying with burdensome regulations from Washington, D.C.” Comments are due to CMS by 5pm on August 28, 2017.
ESRD base rate to increase by $1.76; total payments by .8%
CMS annually updates the base rate for renal dialysis services furnished to Medicare beneficiaries. This bundled payment includes all services furnished for outpatient maintenance dialysis, including certain drugs. This rate can be adjusted up or down based on patient or facility characteristics and outlier payments for high-cost patients. In 2018, CMS expects to pay $10 billion to 6,750 dialysis facilities under the ESRD PPS. This includes a proposed increase of $1.76 to the base rate, bringing the total PPS base rate to $233.31.
As noted, payments under the PPS amount may vary due to a number of factors. For 2018, CMS does not propose any changes to the wage index and wage floor factors. CMS also proposes minor changes to the outlier payments for high-cost patients, based on 2016 claims data. In 2016, outlier payments comprised .7% of total ESRD payments, and CMS expects that these changes will increase these payments while still keeping the total under the 1% target.
In addition, as some drugs and biologics delivered to dialysis patients do not have an average sales price (ASP), the CMS proposes to make other pricing methodologies available to Medicare Administrative Contractors, including Wholesale Acquisition Cost and Average Manufacturer Price. CMS also proposes to update the Acute Kidney Injury (AKI) dialysis rate to match the ESRD PPS rate of $233.31.
Taken together, CMS estimates that these proposed changes will increase payments to all ESRD facilities by .8%, with hospital-based ESRD payments to increase 1% overall.
ESRD QIP to include AKI patients; CMS solicits comments on inclusion of social risk factors
The ESRD program includes a Quality Incentive Program (QIP) that includes a variety of performance measures on which ESRD facilities must report and reduces payments (by up to 2%) to those facilities that do not meet a minimum scoring threshold. CMS believes that the Trade Preferences Extension Act of 2015 provides them with statutory authority to include the AKI population in the QIP for the first time, and seeks comments on how best to include these patients. In addition, CMS requests comments on whether and how they could account for social risk factors in the QPP, including which risk factors are most appropriate for the program.
The proposed rule includes a number of changes in future years, the most notable of which is a change to the measures included in the QIP in CY 2021. This will eliminate the Vascular Access Type measure and replace it with Standard Fistula Rate and Long-Term Catheter Rate measures recently endorsed by the National Quality Forum (NQF). CMS also proposes to use CROWNWeb, a Medicare dialysis data reporting tool, rather than claims data as the primary data source for these new measures. They also propose NQF-consistent revisions to the Standardized Transfusion Ratio measure.
CMS requests information on Medicare Flexibilities and Efficiencies
Consistent with general requests elsewhere, the ESRD proposed rule requests suggestions from the public on changes they could make to the program in order to reduce burdens, improve the quality of care, decreased costs, and ensure that patients and providers make the best health care choices possible. Although CMS notes that they will not respond to these suggestions in the final rule, they request that proposals be clear, concise, and consistent with current law.
No mention of DMEPOS policy changes
For the past several years, CMS has generally consolidated changes to durable medical equipment, prosthetics, and orthotics policy in the ESRD proposed rule, including changes to the DME competitive bidding program. This year, they did not include a reason for their decision not to do so. Applied Policy will continue to monitor developments in DMEPOS policy, and will post them on this blog as they become available.
If you have any questions about ESRD, DMEPOS, or any other health policy challenges faced by your organization, Applied Policy is ready to help. Please contact us at gpugh@appliedpolicy.com or 202-558-5272 and let us know how we can partner with you in improving the lives of the patients you serve.