Reading the tea leaves: does CMS transmittal signal oral drugs are not in the bundle?

By Bill Peckham

I was interested to read The CMS's Program Transmittal on Dialysis Adequacy, Infection and Vascular Access Reporting (PDF link) that was linked to by RenalWEB and NephrOnline. The transmittal relates to the Quality Improvement Program (QIP) that is a feature of the Prospective Payment System (PPS) required by the Medicare Improvements for Patients and Providers Act (MIPPA). After providing background the transmittal lays out new reporting requirements:

B. Policy: The CMS will require the reporting of the Kt/V reading and date of the reading, vascular access and infection data on ESRD claims with dates of service on or after July 1, 2010. This new data reporting requirement will allow CMS to implement an accurate quality incentive payment for dialysis providers by January 1, 2012, as required by MIPPA §153c. CMS is requesting a July 2010 implementation date because the quality incentive payment must be in part based on provider improvement over time, thus, CMS requires an accurate measurement of baseline provider performance. The CMS will require that providers continue to report the existing G1 through G6 modifiers for URR at this time.

There is no mention of bone measures. Does this mean that oral drugs will not be included in the PPS required by MIPPA? Like the dog that did not bark, it is suggestive.

As the transmittal notes for a measure to be included in the QIP, CMS has to establish a baseline. As it stands, there isn't data for the sorts of reporting you would want to have in place if oral drugs were going to be part of the PPS. If CMS was planning to include oral drugs I would expect them to measure bone health outcomes e.g. PTH, calcium, phosphorus. If the transmittal included phosphorus or PTH, their inclusion would signal that CMS is preparing to include oral drugs (in the foreseeable future). However, you can't be sure their absence signals oral drugs are out. There could be another transmittal on the way!

We'll have to keep watching, and reading the tea leaves until the final rule is released in the next several months. When, exactly, is that going to be? I'd say April if it is an interim rule (another comment period!); June if the rule is released in final form. These are just a wild eyed guesses on my part, however, pushing the QIP implementation into 2012 (I think this transmittal means 2012 will be the first year payment is at risk/2011 would be the base year) signals that the expected round of proposed rule making focusing on the QIP is going to be held off until the final PPS rule is released.

The final rule does have to be released sometime this year. In enough time to allow providers time to get ready. If I had to guess one date, I'd take June 30 ... right before the long July 4 weekend.

Comments

[Richard Menard]

What do you think will change in the final rule? I agree that oral drugs, given the number of comments against including them in the bundle, will be dropped. So what can we hang our hats on? Co-morbidity would seem a safe bet, despite the burden put on dialysis providers to collect this information. The July 2010 mandate to include infection on the claim suggests to me that co-morbidity reporting is certain. The transition period where 25% of each claim is paid under the bundle and the rest under the old rules is particularly difficult to implement from a billing perspective. Systems design and development has to begin before the final rule is published; if we wait until July 4th, it will be difficult to be ready by 1/1/11.

[Bill Peckham]

I enjoy a good wager but betting on any element of the bundle would require odds. I think the odds favor the exclusion of oral meds but we won't know until they release the rule.

No one has to phase in - it is an option to just jump in on 1/1/11, that said you're right that there is a lot to prepare. I think this pushes back against the idea of an interim rule.

What do I think will be in the final rule? I think CMS should act on my comment in its entirety, but really the one thing that needs to be in there from my reading of the comments, particularly the comments from beneficiaries, is better accommodation of home training.

I think that CMS could ease the burden of implementing the rule by eliminating the majority of case mix adjusters. That's one thing I'll be very interested to read when the final rule comes out - how many case mix adjusters are they going with - I hope the transmittal is signaling they are moving infection from case mix to QIP where it belongs.

Anyone else have wild eyed guesses they'd like to share?