More coverage of CMS's CROWNWeb implementation rethink

By Bill Peckham

Inside CMS has an article up reporting (by subscription, January 22, 2009) CMS Delays Full CROWNWeb Roll Out, Opts to Evaluate in Phases (pdf link):

CMS has decided that the end stage renal disease (ESRD) CROWNWeb reporting system, scheduled to begin for all dialysis organizations on Feb. 1, will now be phased in with just a select group of facilities nationwide participating on the start date. Though few details were included in the Jan. 16 memo to congressional health staff and ESRD networks, an agency official tells Inside CMS the first-phase participants will be determined largely on geographic diversity -- urban versus rural -- so CMS can get an accurate read of the factors involved in rolling out the system based on differing financial burdens, facility practices and patient populations.

The article credits the lobbying efforts of the National Renal Administrators Association (NRAA), small dialysis organizations (SDOs) and in particular the Northwest Kidney Centers (misidentified as Northwest Kidney Partners) for leading the advocacy that led to CMS rethinking the CROWNWeb roll out. It's interesting that the two largest industry groups - Kidney Care Partners and Kidney Care Council - never published a word about the problems with the initial roll out plan. I think this is a lesson that the industry needs many voices.

The Inside CMS article goes on to quote a Democratic Congressional aide who says that the goal is still to get "ESRD bundling rolled out on time with a strong quality component". This is a reminder that the point of CROWNWeb is to provide data on the impact on patient care of expanding the bundle, and to provide data to implement the 2% reimbursement withhold that is mandated in HR 6331 (pdf link, see page 171) the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008.

Expanding the payment bundle is a complex undertaking; CROWNWeb, once it is fully implemented, is to provide timely data to confirm that there isn't any deterioration in outcomes. One obvious concern with adding previously separately billable medications e.g. Epo, Iron, to the expanded bundle is that they will be under used. CROWNWeb is suppose to be able to identify trends such as  falling hematocrits early so that corrective action (yet to be identified) can take place.

The second job for CROWNWeb is to feed data to the process to implement the 2% quality (really lack of quality) withhold that was created by MIPPA. This measure has not received much attention because there are still many details to be decided. I don't remember any discussion about whether, as a matter of policy, it is  better to reward good performance or punish bad results. The MIPPA provides the Secretary of DHHS with authority to reduce payments by "up to 2.0 percent" based on mostly blood measures including anemia measures in light of FDA recommended dosing, iron management, bone mineral metabolism and one non blood measure - vascular access with the goal of promoting fistula use.

It raises a lot of questions, the details of implementation will be key but nothing can happen without outcome data and that is why CROWNWeb is so important. All the reporting I've seen has been clear the the NRAA and the SDOs support the goals of CROWNWeb and the need for CROWNWeb, it was the specific way it was being implemented that created a problem.