The demands on the nephrology practice

Schmidt

Practicing nephrology is an evolving process. Government regulations, quality initiatives, and reimbursement adjustments change the working environment. And the growing workforce shortages create uncertainty. I spoke with Rebecca J. Schmidt, DO, president of the Renal Physicians Association, professor of medicine and chief of the section of nephrology at West Virginia University in Morgantown, W.V., about the obstacles facing the profession, areas where nephrologists and the specialty can improve, and advances made during her presidency at RPA. The organization is holding their annual meeting March 17-20 in Phoenix, Ariz.

Supply of nephrologists becomes smaller, demands on individual physicians grow

Data from the U.S. Nephrology Workforce 2015 Development and Trends report, released in October 2015, show an 8% drop in new nephrology fellows in 2014 and predict a further drop in 2015. This dwindling number of nephrologists disproportionately affects rural areas, Schmidt said. Patients in rural areas are also geographically spread out, which "necessitates excessive physician travel to distant sites."

As electronic health records have become ubiquitous, Schmidt said a lack of interoperability between systems, practices, and providers is a growing problem. The issue is multiplied by the number of dialysis companies with which a nephrologist is affiliated. "EHR interoperability is the single most significant area in need of improvement; this affects all aspects of providing care, including staff and resources (retrieving needed patient information), time management (charting by electronic entry is difficult to delegate securely) and patient safety (having the necessary medical information)."

Administrative burdens are a major area of concern for nephrologists, she said. Changes in government regulations and EHRs have increased the amount of time nephrologists and other physicians must spend performing data entry. As the Centers for Medicare & Medicaid Services works on creating quality measures for physicians, including the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Models (APMs), Schmidt said she hopes the agency will be mindful of administrative burdens.

"To the extent that the MIPS program continues the dynamic of forcing nephrologists and other physicians to increase the degree of administrative activities and data entry necessary to fulfill MIPS requirements, it is hard to see how that benefits patient care. Hopefully CMS will minimize such administrative burdens," she said. "MIPS and APMs will certainly affect the practice of nephrology, but since the rulemaking is still in the embryonic stage no one really knows how this will play out. It is clear that the measurement of nephrology practice will continue and advance, and that there’s a likelihood that a larger share of a nephrologist’s reimbursement will be based upon that measurement."

CMS recently released a draft of the Quality Measure Development Plan, giving some insight into how the agency will frame its new quality measurement programs. "The Quality Measure Development plan seems like a very comprehensive and thoughtful approach to what CMS is going to do with measures and how they're going to implement MACRA [Medicare Access and CHIP Reauthorization Act]," Schmidt said. "Interestingly, it devotes some time discussing an evidence-based justification for measure development, but it seems that they are also reasonably open to measures that are not founded solely on evidence if there's none to be found, which could be of concern down the road if unvetted measures are implemented for expediency’s sake. It does take a very broad, medicine-wide view of these issues so we’re nowhere near being able to assess whether it would impact the MCP [Medicare Capitated Payment]. Historically the ‘silo effect’ at CMS kept these activities quite separate but given the emphasis on value-based care, this could be subject to change."

Medicare Physician Fee Schedule

Nephrologists won’t see a difference in their monthly capitated payment for patients in 2016, but the final Medicare Physician Fee Schedule, which went into effect Jan.1, does include some new changes for physician services. "In recent years nephrology has not experienced substantial change vis a vis the Medicare Fee Schedule, and this should be considered positive in relative terms," Schmidt said. "Many specialties that have experienced change experienced a downward valuation of some of the services they commonly provide."

Adding home dialysis to the category 1 telehealth list was a significant aspect of the new fee schedule, she said. "Since the home is not an approved site, the options for seeing home dialysis patients by telehealth are limited; the CONNECT bill is a step in the right direction because it allows the dialysis unit to be a designated site and eliminates geographic rural restrictions, but does not include the home as an originating site,"Schmidt said.

The ESRD population is in great need of advanced care planning, she said, and an introduction of advance care planning codes that do not exclude ESRD patients was also an improvement.

Chronic Kidney Disease Improvement in Research and Treatment Act

Congress introduced the Chronic Kidney Disease Improvement in Research and Treatment Act of 2015 (H.R. 1130, S. 598) in Feb. 2015. It aims to improve the coordination of care, promote patient access and choice, expand research and enhance coordination. An earlier version of the bill was also introduced in 2014. "Hopefully the bill will pass this year and not need to be reintroduced until next year and the next Congress," said Schmidt. I asked her to list what she thinks are the highest priorities from the bill.

Loan forgiveness for nephrologists would help reduce disincentives to entering/choosing nephrology as a profession.

Allowing ESRD patients to enroll in Medicare Advantage.

Providing more stability in facility payment practices.

Advances and improvements made

The RPA has helped make legislative advancements during Schmidt's presidency, and I asked her to discuss some of the most significant improvements.

"After more than a decade, we witnessed the end of the sustainable growth rate (SGR) methodology for physician payment when the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) was signed by the president last April. MACRA included provisions addressing two other RPA legislative priorities: Federal funding for quality measure development and federal oversight for measure development. Congress also passed legislation last year that included a provision approving payment for dialysis in outpatient ESRD facilities for Medicare beneficiaries with acute kidney injury.

"I’m very proud that during my presidency (in March 2015) we launched the RPA Kidney Quality Improvement Registry, the only nephrology-specific Qualified Clinical Data Registry. Data in the registry may be used to participate in multiple professional (e.g. Maintenance of Certification) and incentive reporting programs (e.g. PQRS, MU), as well as for quality improvement. Significantly, the registry included 10 non-PQRS measures in 2015, allowing more nephrology-specific reporting options than the traditional PQRS measures."