Published by MedPage Today
Joyce Frieden
July 7, 2014

The Centers for Medicare and Medicaid Services plans to keep payments for end-stage renal disease (ESRD) care virtually flat in 2015.

In its proposed rule CMS said it would increase total payments to all ESRD facilities in 2015 by an estimated 0.3% compared with 2014. However, hospital-based ESRD facilities would get a slightly higher increase (0.5%), as will facilities in urban areas (0.4%).

ESRD facilities in rural areas, on the other hand, will receive a 0.5% payment decrease, and facilities in Puerto Rico and the Virgin Islands will fare even worse, with a 3.6% decrease.

Spending for ESRD has long been a trouble spot for Medicare. In 2010, for example, ESRD patients made up just 1.3% of the Medicare population but accounted for nearly 7.5% of spending, with a bill of more than $20 billion. In February 2013, CMS announced a new program — the Comprehensive ESRD Care Model — that would allow ESRD providers and suppliers to work together to test out different payment models as part of an effort to decrease ESRD costs.

The flat payment update was not unexpected, since CMS had announced earlier that payments would remain flat next year, followed by gradual decreases through 2018, explained Tonya Saffer, senior federal health policy director for the National Kidney Foundation.

What worries Saffer, however, is the proposed decrease for rural ESRD facilities. “What’s concerning is that if [ESRD providers] are looking to further improve efficiencies, they may look to close facilities that are losing money,” including rural facilities, she told MedPage Today.

The proposed decrease in payments to rural facilities — and dialysis centers in Puerto Rico and the Virgin Islands — occurred because CMS decided to revise the “market basket” number for estimating the overall costs of dialysis, using 2012 numbers instead of the 2008 figures they had previously used, Saffer explained.

Since drug use by dialysis facilities — a component of the market basket — had declined in the interim, “that increases the [significance of the] wage portion of the market basket update, so for areas that have a lower wage index [such as rural areas], it’s resulting in the update being negative,” she said.

Both Saffer and Rachel Meyer, manager of policy and government affairs for the American Society of Nephrology (ASN), agreed that the update wasn’t as bad as it could have been. “I think it will be a challenge for many providers to navigate a 0% update but it is better than what would have happened otherwise,” Meyer told MedPage Today.

Also of interest in the proposed rule are changes to the Quality Improvement Program for dialysis centers, which financially rewards or penalizes the centers depending on whether or not they meet certain self-reported performance criteria. In particular, the agency proposed implementing a standardized hospital readmission measure.

“The ASN strongly supports the concept of the proposed readmission measure, and it has lots of potential to improve care,” Meyer said. “But there are serious questions regarding implementation of the measure … There are a lot of challenges in the methodology and questionable aspects that lack validity. And the measure has not been approved by the National Quality Forum.”

For example, “one thing we think might be unfair,” she continued, “is that it is possible that dialysis centers might be held responsible for patients being readmitted who hadn’t been back to dialysis facilities prior to being readmitted. There are some methodological concerns that could be addressed.”

On the brighter side, CMS is also proposing to remove one measure from the Quality Improvement Program — the percentage of patients who achieve hemoglobin greater than 12 g/dL — “on the grounds that it is ‘topped out,'” — that is, most centers are already achieving that goal, the agency said in its proposal.

This is a good idea, Meyer said. Leaving in topped-out measures “dilutes the effectiveness of measures that are important and not achieved.”

Another proposed change to the program is to add a standardized transfusion ratio — the percentage of patients in the facility that have had a blood transfusion. “They say the concern is that the bundled [payment] environment provides an incentive to undertreat anemia in a dialysis facility,” said Saffer. “Also transfusions in people seeking transplantation can cause sensitivity and make it more difficult to find a transplant match.”

CMS is hoping the transfusion measure would serve as a “floor” for dialysis facilities to encourage them to perform transfusions when necessary, she added. “On the other side of that, it’s not the best measure because it could have the unintended effect of preventing patients from getting a transfusion when it’s necessary — letting the hemoglobin drop so low that it could have an effect on patients’ quality of life.”

CMS will be accepting comments on the proposed rule until early September.

See the original article here.