ESRD final rule gives dialysis providers a slight payment boost

Dialysis providers will see a slight Medicare reimbursement increase in 2018, according to the final rule the Centers for Medicare & Medicaid Services released on Oct. 27. The rule updates payment policies and rates under the End-Stage Renal Disease Prospective Payment System (PPS) for dialysis services furnished to beneficiaries on or after Jan. 1, 2018.

This rule includes updates to the acute kidney injury dialysis payment rate for ESRD facilities to the ESRD Quality Incentive Program (ESRD QIP), including for payment years (PYs) 2019, 2020, and 2021. Below is a brief summary provided by CMS. NN&I will provide further analysis in the coming weeks.

Update to base rate

The CY 2018 ESRD PPS base rate is $232.37, an increase of $0.82 to the current base rate of $231.55. This amount reflects a reduced market basket increase as required by section 1881(b)(14)(F)(i)(I) of the Act (0.3%) and application of the wage index budget-neutrality adjustment factor (1.000531).

Wage Index and Wage Index Floor

For CY 2018, CMS did not change the application of the wage index and will continue to apply the current wage index floor (0.4000) to areas with wage index values below the floor.

Update to the Outlier Policy

CMS is updating the outlier services fixed-dollar loss (FDL) amounts for adult and pediatric patients and Medicare Allowable Payment (MAP) amounts for adult patients for CY 2018 using 2016 claims data.

Based on the use of more current data, the FDL amount for pediatric beneficiaries will decrease from $68.49 to $47.79 and the MAP amount will decrease from $38.29 to $37.31, as compared to CY 2017 values.

For adult beneficiaries, the FDL amount will decrease from $82.92 to $77.54 and the MAP amount will decrease from $45.00 to $42.41. In CY 2016, outlier payments were 0.78% of total ESRD PPS payments, that is, slightly less than the 1.0% target for outlier payments. Using CY 2016 claims data to update the outlier MAP and FDL amounts for CY 2018 will increase outlier payments for ESRD beneficiaries requiring higher resource utilization.

Impact analysis

CMS projects that the updates for CY 2018 will increase the total payments to all ESRD facilities by 0.5% compared with CY 2017. For hospital-based ESRD facilities, CMS projects an increase in total payments of 0.7%, while for freestanding facilities, the projected increase in total payments is 0.5%.

Payment for dialysis services for individuals with acute kidney injury

CMS is updating the AKI dialysis rate for CY 2018 to equal the final CY 2018 ESRD PPS base rate and to apply the final CY 2018 wage index. For CY 2018, the final AKI payment rate is $232.37.

Changes to ESRD QIP

Updates to the Extraordinary Circumstances Policy

CMS will require that facilities submit their Extraordinary Circumstances Exception (ECE) request form within 90 days following the date of the extraordinary event. The agency is also expanding the reasons for which an ECE can be requested to include an unresolved issue with a CMS data system which affected the ability of the facility to submit data. The facility need not be closed to request an ECE exception, as long as the facility can show that its normal business operations were significantly affected due to an extraordinary circumstance beyond the control of the facility.

Replacement of existing measures with new and improved measures

CMS is finalizing the replacement of the current Vascular Access Type clinical measures with two new measures—the Hemodialysis Vascular Access: Standard Fistula Rate Clinical Measure and the Hemodialysis Vascular Access: Long-Term Catheter Rate Clinical Measure—that were recently endorsed by the National Quality Forum (NQF), beginning in PY 2021. The agency is also revising the Standardized Transfusion Ratio clinical measure effective for PY 2021 so that the specifications for that measure align with updates endorsed by the NQF.

Kidney Care Partners, a coalition of physician groups, providers, patient groups, manufacturers and researchers, gave NN&I the following statement shortly after the rule was released:

“While we are still reviewing the Rule which has just been made available this afternoon, we are pleased that CMS has decided not to finalize its proposal to incorporated patients with Acute Kidney Injury (AKI) and receive dialysis into the QIP since the treatment options and appropriate outcomes differ significantly from patients whose kidneys have permanently failed. We are also pleased that CMS has included the small increase in the base rate, consistent with the statute.

"We remain concerned, however, that CMS continues to expand the quality measures in the QIP in contrast to MedPAC’s recommendations to reduce measures in such programs. We are also disappointed that CMS has no addressed the methodological flaws that MedPAC and the kidney care community have identified, but we look forward to working with the Administration to address these issues going forward." - Rebecca Zumoff