Details for: CMS PROPOSES NEW PROSPECTIVE PAYMENT SYSTEM FOR RENAL DIALYSIS FACILITIES
For Immediate Release: Tuesday, September 15, 2009
Contact: CMS Office of Public Affairs
202-690-6145
CMS PROPOSES NEW PROSPECTIVE PAYMENT SYSTEM FOR RENAL DIALYSIS FACILITIES
PROGRAM WOULD REWARD EFFICIENT, HIGH QUALITY CARE FOR PEOPLE WITH END-STAGE RENAL DISEASE
The Centers for Medicare & Medicaid Services (CMS) today proposed a new prospective payment system (PPS) for facilities that provide dialysis services to Medicare beneficiaries who have end-stage renal disease (ESRD).
The proposed PPS would provide a single bundled payment to dialysis facilities that would cover the items and services used in providing outpatient such services, including the dialysis treatment, prescription drugs, and clinical laboratory tests.
The new payment system, which was required by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), is designed to improve the efficiency of care, while promoting high quality services. Today’s notice proposes three quality measures that CMS plans to use for its quality incentive program (QIP) and lays out a conceptual model for public comment.
“Combining a fully bundled prospective payment system with required performance standards would encourage facilities to operate more efficiently and ensure that beneficiaries receive high quality care, while saving dollars for both beneficiaries and the Medicare program,” said Jonathan Blum, director of the CMS Center for Medicare Management.
ESRD is the only category for Medicare eligibility that is based on a specific diagnosis, without regard to the age of the patient. Patients diagnosed with ESRD must rely on dialysis or receive a kidney transplant for survival. In 2007, there were about 591 hospital-based and 4,330 freestanding ESRD facilities furnishing outpatient dialysis services to nearly 330,000 Medicare patients. This total cost of this service was $9.2 billion including the dialysis service and other ESRD-related items such as drugs.
ESRD services are furnished on an outpatient basis in independent or hospital-based dialysis facilities. Currently, Medicare pays for certain dialysis services under a partial bundled rate, referred to as the composite rate. Payments for these composite rate services represent about 60 percent of total Medicare payments to ESRD facilities. The remainder of Medicare spending for dialysis services is for separately billed items such as drugs, but may also include laboratory services, supplies and blood products.
Under the proposed rule, CMS would establish a base bundled payment rate of $198.64 for all of the services related to a dialysis session, including the services in the current composite rate as well as items, including oral drugs that are billed separately. The proposed base rate was derived from 2007 claims data for both composite rate and separately billable services and updated to reflect projected 2011 prices. It would also be adjusted for case mix factors such as the patient’s age, gender, body size, and time on dialysis. A special case-mix adjustment would apply to pediatric patients. Additional adjustments to the payment rate would be made for specific conditions, or co-morbidities that have a significant impact on a course of treatment. By accounting for more characteristics of patients, the new PPS would target payments more appropriately, paying higher rates to those facilities with the most costly patients.
The base rate would also be adjusted to reflect geographic differences in labor costs. In addition, CMS is proposing to provide an adjustment for low-volume facilities, as well as an outlier policy that would make an adjustment for particularly expensive cases.
CMS will accept comments on the proposed rule through November 16, 2009, and will respond to them in a final rule to be issued in 2010. The new payment system would apply to dialysis services furnished to Medicare beneficiaries on or after January 1, 2011.
For more information, please see: cms.hhs.gov
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Details for: QUALITY INCENTIVE PROGRAM PROVISIONS INCLUDED IN ESRD PROSPECTIVE PAYMENT PROPOSED RULE
For Immediate Release: Tuesday, September 15, 2009
Contact: CMS Office of Public Affairs
202-690-6145
QUALITY INCENTIVE PROGRAM PROVISIONS INCLUDED IN ESRD PROSPECTIVE PAYMENT PROPOSED RULE
OVERVIEW: The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires the Centers for Medicare & Medicaid Services (CMS) to develop and implement by January 2011, a fully bundled prospective payment system (PPS) for dialysis services furnished to Medicare beneficiaries who are diagnosed with end-stage renal disease (ESRD).
MIPPA further requires CMS to create a quality improvement program (QIP) that would help ensure that ESRD facilities furnish high quality care to their patients. The QIP would have payment consequences beginning for services furnished on or after January 1, 2012.
The new payment system would institute financial incentives that tie payment to improving dialysis quality and outcomes. CMS expects the new system would result in both better care and reduced cost for beneficiaries and the program.
BACKGROUND: Section 153(c) of MIPPA requires CMS to develop a Quality Incentive Program (QIP) to promote improved patient outcomes by, for the first time, tying a facility’s Medicare payment rate to how well the facility performs on quality of care measures. Facilities that do not meet or exceed minimum performance standards in a period determined by the HHS secretary will receive payment reductions of up to two percent for a specified year.
The law also requires CMS to select measures and develop performance standards for health care categories such as anemia management and dialysis adequacy. In choosing measures, MIPPA instructs CMS to consider the availability of data to calculate such measures. In addition, as part of this program, CMS must develop procedures for making the QIP information public, after giving providers and facilities an opportunity to review the information that is to be released.
The program will be the first time in which CMS would directly link payments to quality of care. In the past, CMS has used a pay-for-reporting framework for inpatient and outpatient hospital services, and physician services.
This proposed rule for establishing an ESRD PPS outlines how CMS intends to proceed with the QIP and proposes the measures that will be included in the QIP. Performance standards and other implementation issues will be addressed in a separate proposed rule.
QIP PROPOSALS IN THE ESRD PPS PROPOSED RULE: The ESRD PPS proposed rule proposes the following three specific measures that will apply to the initial performance period of the QIP:
Hemodialysis Adequacy: Achieved urea reduction ratio (URR) of 65 percent or more; and Anemia Management: Controlled anemia, as shown in two measures:
* the percentage of patients at a facility whose hemoglobin levels were less than 10 grams per deciliter (g/dL), and
* the percentage of patients at a facility whose hemoglobin levels were greater than 12 g/dL.
The proposed measures were chosen because dialysis facilities have used them since 2001. These measures are currently collected from Medicare dialysis facility claims so there is no need for separate reporting. Finally, CMS already has data on these measures which it can use to develop and test models for the operation of the QIP.
As required by law, CMS plans to establish performance standards for each of the measures and facilities would be scored based on their adherence to the measures. Providers and facilities that do not meet or exceed the total performance score during a performance period would see up to a two percent reduction from their payment rates in the succeeding year.
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 more information, please see: cms.hhs.gov |
