Health Law Daily Quality measures emphasized, hemodialysis equivalency scrapped in ESRD Final rule
Monday, October 31, 2016

Quality measures emphasized, hemodialysis equivalency scrapped in ESRD Final rule

By Kayla R. Bryant, J.D.

The end-stage renal disease (ESRD) prospective payment system (PPS) base rate for calendar year (CY) 2017 is $231.04. In an advance release of the ESRD PPS Final rule (to be published in the Federal Register on November 4, 2016), CMS decided not to establish an equivalency payment methodology for hemodialysis (HD) when more than three treatments are provided in a week. The agency also updated requirements for the ESRD quality improvement program (QIP) for payment years (PYs) 2018-2020.

PPS. As proposed, the new PPS base rate reflects a final market basket increase of 0.55 percent (see Quality Incentives, bidding program updates lead way in 2017 ESRD PPS, June 30, 2016). This increase is required by section 3401 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). CMS has not changed the wage index floor. The agency has chosen to raise the outlier services fixed dollar loss amounts for pediatric beneficiaries to $68.49, while the amount for adult beneficiaries will decrease to $82.92. The impact of the 2017 changes result in a 0.9 percent increase in payments to hospital-based ESRD facilities, while freestanding facilities will receive about 0.7 percent more. About 6,000 ESRD facilities will receive about $9 billion from the Medicare program for costs associated with providing dialysis services under the ESRD PPS.

Hemodialysis. CMS reimburses facilities for up to three HD treatments per week, only paying for more weekly sessions when treatments are medically justified due to specific comorbid diagnoses. In 2011, CMS adopted a per treatment unit of payment for HD and peritoneal dialysis (PD). If a plan of care requires more than three treatments per week, payment edits are applied to ensure that additional payments are denied. Based on the limited amount of information available on the benefits of more frequent HD, CMS has chosen to allow Medicare administrative contractors (MACs) to approve additional treatment instead of changing the payment policy altogether to create equivalency payments as originally proposed. In the future, billing clarifications will be released to ESRD facilities and MACs regarding a mechanism for reporting all treatments, whether medically justified or not. CMS chose to finalize its proposal that the full ESRD PPS base rate will be paid for all training treatments, even if they exceed three times per week, with a limit of 25 sessions.

Dialysis facility compare. The dialysis facility compare (DFC) site, which provides information on Medicare-certified dialysis facilities for patients, will have two new quality measures and modifications to the calculations for facility star ratings, implemented based on patient feedback. The standardized infection ratio (SIR) measures the number of bloodstream infections observed versus the number predicted for a facility. The pediatric peritoneal dialysis Kt/V measure is the percentage of eligible pediatric peritoneal dialysis patients who had enough waste removed from their blood during treatment. The new star rating calculation methodology establishes a baseline to assess year-to-year changes in performance standards, allowing star ratings to reflect a facility’s improvement or decline in performance. The methodology will limit the impact of extreme outlier performances on single measures.

QIP. Starting with PY 2019, the National Healthcare Safety Network (NHSN) Dialysis Event Reporting Measure will be reintroduced into the ESRD QIP measure set, along with a new NHSN Bloodstream Infection (BSI) measure. In PY 2020, the Mineral Metabolism Reporting Measure will be replaced with the Serum Phosphorus Reporting Measure, and the Standardized Hospitalization Ratio (SHR) Clinical Measure and the Ultrafiltration Rate Reporting Measure.

MainStory: TopStory ReimbursementNews IPPSNews CMSNews BillingNews ESRDNews OPPSNews QualityNews

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