CMS to Update the Benefit Manual for ESRD PPS

CMS details in a recent publication of the “MLN Matters” an implementation date of September 9, 2013 for the revisions to the "Medicare Benefit Policy Manual”.  The manual will be updated to reflect change request (CR) 8261 providing information on the end-stage renal disease prospective payment system (ESRD PPS).

 The background and implication of the ESRD PPS, are as follows:

·         In August 2012, CMS released an analysis of patient claims in the new ESRD prospective payment system, which showed that this payment system has had no negative effects on patients’ health.

·         The ESRD PPS, first implemented in 2011, expands renal dialysis services included in the single bundled payment to the dialysis facilities and provides for patient case-mix adjustments, facility level adjustments, and outlier payments.  It is intended to improve efficiency. 

·         CY 2013 will be the third year of a four-year transition to the new payment system.  The overall impact of the CY 2013 changes is projected to be a 3.0 percent increase in payments. Hospital-based ESRD facilities have an estimated 3.6 percent increase in payments compared with freestanding facilities with an estimated 2.9 percent increase. Urban facilities are expected to receive an estimated payment increase of 3.0 percent compared to an estimated 2.9 percent increase for rural facilities.

·         The ESRD QIP aims to promote continued improvement in the quality of care provided to patients with ESRD. The final rule focuses on clinical measures and has added the following QIP reporting measures to cover a broader range of patients who receive dialysis care:

o   To evaluate anemia management

Anemia Management, a reporting measure.

o   To evaluate dialysis adequacy

A clinical Kt/V measure for adult hemodialysis patients.

A clinical Kt/V measure for adult peritoneal dialysis patients.

A clinical Kt/V measure for pediatric in-center hemodialysis patients.  

·         The overall economic impact of the ESRD QIP is an estimated $24.6 million for PY 2015. The total expected payment reductions will be approximately $12.1 million, and the costs associated with the collection of information requirements for certain measures to be approximately $12.4 million.

·         The estimated payment reduction will continue to incentivize facilities to provide higher quality care to beneficiaries. The reporting measures that result in costs associated with the collection of information are critical to better understanding the quality of care beneficiaries receive, particularly a patient's experience of care, and will be used to incentivize improvements in the quality of care provided.

For the final rule, click here.

To access the ESRD PPS and ESRD QIP, click here.