By Bill Peckham
The Centers for Medicare & Medicaid Services (CMS) today proposed a new prospective payment system (PPS) for dialysis services provided to Medicare beneficiaries (press release). These new rules have been anticipated since the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) was approved by Congress and became law in July of last year.
One element of the dialysis program legislation in MIPPA is a quality improvement program (QIP) that is intended to motivate improved quality at facilities. CMS published a separate fact sheet on the QIP provisions in the proposed rule - basically they are going to start with two of the three measures reported on CMS's Dialysis Facility Compare (DFC) website (reported on DFC but not being used is patient survival). The two measures being proposed are hemodialysis adequacy and anemia management (both above and below the target range) . CMS did not come out with many details, for instance what percent of providers would be subject to the withhold, but they are strongly inviting comments:
CMS will accept comments on this conceptual QIP model in the ESRD PPS proposed rule through November and will issue a separate proposed rule based on consideration of the comments received at a future date.
For the next 60 days CMS is asking for feedback on the entire rule but this is one of a number of areas CMS is making a specific request for input; this request will, I think, generate many comments. After the first read I'm wondering why not include unit mortality rates which are a part of DFC? And why not go beyond DFC and draw from the KECC Dialysis Facility Reports which include things such as hospitalizations and infections? (view actual Dialysis Facility Reports here)
The QIP model is one piece of MIPPA's task for CMS. The other piece, I would say more important piece, is to put in place a new system for how dialysis will be reimbursed. CMS published a fact sheet on the PPS for dialysis (aside from the QIP model) and the entire 547 page PDF explaining and detailing CMS's choices is available (LARGE PDF FILE link).
When I first saw the report the first thing I wanted to know is the payment frequency - would payments be per treatment, weekly, monthly or something else. The idea of a monthly bundle is very problematic and to their credit CMS went with a per treatment payment scheme. CMS is proposing to base the bundle on a per treatment basis.
The unit of payment section of the 547 page document starts on page 58. The key sentence is on page 60:
We propose to continue the present per treatment basis of payment in which ESRD facilities would be paid for up to three treatments per week, unless medical necessity justified more than three weekly treatments.
This is a big relief. Not only the per treatment payment but very important is allowing for medically justified treatments beyond the standard 3 per week. More on this in future posts.
There is a lot to digest and blog about. The rule includes training for home hemodialysis in their calculation of a PPS - this means low reimbursement for intense and extended training, one-on-one training for weeks at a time. This is a concern since it would create or make worse a barrier to improving home hemodialysis access. Access to the healthiest forms of dialysis should not depend on your zip code. This is an area CMS asked for input and will, I think, generate many comments.
The base payment rate that CMS came up with is $198.64, which seems very low but it'll take some time to figure out how to compare that number with current reimbursement. For instance I think the $198 represents the lowest payment under the new bundle, whereas current reimbursement adjusted the base rate both up and down. CMS also is proposing that the beneficiary coinsurance amount be 20% of the bundled payment amount, including applicable case-mix adjustments and outlier payments. This represents a change in that lab tests that previously were 100% paid by CMS now are part of the bundle and 20% of the cost is the responsibility of the patient or their secondary insurer.
The entire idea that fractional payments are included in each per treatment payment under the expanded bundle does not seem to be addressed. A per treatment expanded bundle payment means that in that payment there is partial reimbursement for things like the labs that are not currently in the composite payment. For instance the new Conditions for Coverage require semi-annual tests for hepatitis, a test that cost hundreds of dollars. Something like five dollars of the new expanded per treatment payment should be intended to pay for this semi-annual test so that after six months of treatments the unit has received full reimbursement (78 fractional payments) for the test.
In this example you can see the problems. For one, the bundle is based on 2007 costs which was when they did the test yearly - it's now done twice as often. How is that accommodated? Then there is the issue flowing from hospitalizations and travel. If during the six months the patient is traveling or hospitalized while the unit is suppose to be getting the fractional payments for the hepatitis test then the unit will not be fully reimbursed. The unit will still be obligated to have the test done once the patient returns even though they have not been fully reimbursed. You can anticipate this same sort of fractional payment issue with any service not provided each treatment in 2007 - iron for instance to name another big one; there are other medications and lab tests that are in the same boat.
Labs should have never been part of this but MIPPA required their inclusion, so they're included. However, CMS does have an obligation to construct a way to accommodate missing fractional payments. Fractional payments also feature in questions around medically justified forth treatments.
Obviously there is still a lot to understand but I'm feeling optimistic after my first read. In the next few days it'll be interesting to track the reaction of other dialysis stakeholders who are sure to weigh in. If you've been working through the rule's 547 pages please comment; tell me how you're reading it.