Part 2: HHS leadership, health care reform will impact progress on priorities for nephrology

NN&I asked Donna Bednarski, RN, MSN, ANP-BC, CNN, Kidney Care Partners consultant for the American Nephrology Nurses Association (ANNA), and Robert Blaser, director of public policy for the Renal Physicians Association (RPA), for their thoughts on what the next 12 months could look like on Capitol Hill for the kidney care community. In Part 1, published in the January issue of NN&I (available at www.nephrologynews.com), our policy experts covered the ongoing vacancy at HHS and the rising interest in regulating staff-patient ratios in dialysis clinics. This month, Part 2 continues with a look at physician payment, acute kidney injury (AKI) and outpatient care, and concerns about restricting the use of more frequent dialysis.

NN&I: The Dialysis Patients Demon-stration Act, re-introduced in the U.S. House of Representatives in November 2017, would allow dialysis companies to build new integrated care systems similar to the end-stage renal disease (ESRD) Seamless Care Organizations, but these would not have to be headed up by a nephrologist. Does this put more control in the hands of dialysis providers? Is there a happy medium here that could be hammered out in Congress and will benefit nephrologists?

Robert Blaser: From a nephrology perspective, this is the $64,000 question. Some nephrologists believe the proposed structure for the entities to be created by the Patients Act would be a recipe for nephrologists to strictly be employees of the dialysis company. There is a concern that care decisions would be made by non-clinically based senior management personnel. It is worth noting that in a revision to the original legislation that was sought by RPA, a specific role for the nephrologist on the governing body of the entity is now mandated, presumably providing additional emphasis on the importance of clinical leadership in these organizations.

Conversely, proponents of the legislation assert that any of these entities that subjugated the role of the local nephrologists would likely be destined to fail and the organizations will have an incentive to promote a healthy working relationship with their nephrologist partners. Additionally, the fact that the bill designates the entities as advanced alternate payment models for the purposes of the Medicare Quality Payment Program (QPP) will provide nephrologists who fulfill the qualifying criteria with access to the 5% QPP payment bonus on her or his total Medicare spend. This is obviously positive for participating nephrologists.

Whether some sort of happy medium on this issue could be reached in Congress is difficult to say. The legislation continues to gain co-sponsors in the House but also is being actively opposed by the non-profit dialysis provider community, which would lead one to believe that passage in the 115th Congress will be an uphill battle. If the bill is not enacted in 2018, then it would have to be re-introduced for the next Congress and thus would likely be open for future revision.

NN&I: In January 2017, CMS began covering treatment for acute kidney injury in the outpatient setting. With a year’s worth of experience, what do you and ANNA hear from nurses about how these patients “fit in” within the ESRD outpatient environment? Likewise, what are the best ways to measure the quality of care these patients receive?

Donna Bednarski, RN, MSN, ANP-BC, CNN: More options for care location would allow the right setting for the patient based on acuity of the patient, comorbid conditions and accessibility and convenience, allowing them to receive care closer to their homes with return to work and family life. Care coordination from the inpatient to the outpatient setting is critical to ensure the appropriate care of the patient with AKI. Dialysis clinics offer a safe, financially viable and clinically appropriate setting for dialysis treatments with less risk of exposure to infection or other infectious diseases.

CMS called for comments on the inclusion of patients with AKI in the ESRD Quality Incentive Program. The care and goals of care of the patient with AKI are different than patients with ESRD. Therefore, the quality measures applying to the patient with ESRD would not “fit” the goals of the patient with AKI. The development of quality measures for the patient with AKI will be a challenging task as there are limited protocols or guidelines to establish metrics for AKI. The key is close monitoring for evidence of renal recovery and efforts to facilitate recovery, such as a less aggressive approach to fluid removal to avoid episodes of hypotension. So correctly identifying this patient population is critical in establishing care.

NN&I: The 2018 final rule for the Medicare Physician Fee Schedule and the newly named QPP came out in November 2010. How do these two rules impact the bottom line for nephrologists?

Blaser: Long story short, both rules came out about as neutrally to positively as could be expected for nephrology, given the current climate. The QPP rule was pretty much finalized as proposed, which positively means that nephrologists will receive the highest complex patient bonus of any Medicare specialty, seemingly acknowledging the concerns raised by RPA and other over the years that there must be some sort of risk adjustment or other methodology to account for the complexity of ESRD care.

On a less than happy note, CMS did not extend the use of the “Pick Your Pace” program, which allowed Medicare providers to clear a low bar for avoiding any MIPS penalties. As such, nephrologists and other kidney-based Medicare Part B providers should pay attention in 2018 to successfully participating in merit-based incentive payment system via reporting on the quality, advancing care information and improvement activity components of the program.

Regarding the 2018 fee schedule final rule, in a general sense, nephrology remained as in recent years, even-steven, with a projected 0% specialty-specific impact for the discipline. Reimbursement levels for dialysis services specifically, both inpatient and outpatient, continued to be stable, with little change. The conversion factor (the multiplier expressed as a dollar figure through which Medicare increases or decreases overall reimbursement to Medicare Part B providers) went up about $0.11 for 2018, from $35.88 to $35.99.

CMS reversed the decision made for the 2017 fee schedule and will implement the AMA’s RVS Update Committee-recommended values for the dialysis circuit code family (CPT code 36901-36909), restoring some of the value for these services and resulting in modest payment increases for these services. Additionally, the apheresis code family of services experienced across the board payment increases, resulting in increases of 15% and higher for a majority of the codes. CMS also reiterated its position on the home dialysis code family, reaffirming their status as misvalued codes but providing no specific direction for revaluing the codes.

NN&I: In 2017, a number of Medicare Administrative Contractors proposed changes to policies governing the use of more frequent dialysis. Is the dialysis nursing community concerned about the implications of these policies?

Bednarski: The more options available to patients, the greater the ability to provide individualized care to meet patient needs. Recognizing the clinical benefits of more frequent dialysis in the areas of fluid volume, hypertension, phosphorus and, in some studies, physical function and feeling of well-being would allow for more patients to benefit from the modality. Options for more frequent dialysis would ensure more patients meet their desired goals for medical outcomes, as well as work and home life. With medical justification required for more frequent dialysis, there would be some who would benefit from this modality who would be eliminated. -by Donna Bednarski, RN, MSN, ANP-BC, CNN

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Donna Bednarski, RN, MSN, ANP-BC, CNN, is a Kidney Care Partners consultant for the American Nephrology Nurses Association. Robert Blaser, is the director of public policy for the Renal Physicians Association. Disclosures: Bednarski and Blaser report no relevant financial disclosures.