lazarus-the impact of esrd bundling on nephrology...

1

The Impact of ESRD Bundling on

Nephrology Practice

2013 Heartland Kidney Conference

J. Michael Lazarus M.D. Senior Executive Vice President

Fresenius Medical Care NAJanuary 31, 2013

“Privileged and Confidential for Quality Improvement Review – Do Not Copy”

Medicare Improvements for Patients and

Providers Act

of 2008

MIPPA

• Renal provisions are only one element of many

Medicare reforms under MIPPA

• The law changes dialysis reimbursement from a

partial prospective payment system (composite

rate; drug add-on; separately billable medications;

separately billable lab test) to a fully bundled

prospective payment for dialysis services,

beginning in 2011.


Patient counts, by modalityFigure p.3 (Volume 2)

Incident & December 31 point prevalent ESRD patients.


Distribution of general (fee-for-service) Medicare patients & costs for CKD, CHF,

diabetes, & ESRD, 2000 & 2010Figure p.1 continued (Volume 2)

Period prevalent general (fee-for-service) Medicare patients. Diabetes, CKD, & congestive heart failure determined

from claims, 1999–2000 & 2009–2010; costs are for calendar years 2000 & 2010.


Government’s bundle objectives

Provide equitable payment

Provide access to services

Promote operational efficiency

Enhance quality of care

Encourage Home Dialysis


Renal Community’s Rationale

Starting in 2012 there will be annual increase to the bundled payment amount by an ESRD market-basket percentage minus 1.0 percentage point

2


Renal Dialysis Services

in Bundle• All items and services included in the Composite Rate

for renal dialysis services as of 12/31/10.

• ESR agents and any oral form of such agents that are furnished to individuals for the treatment of ESRD

• Other drugs and biological agents that are furnished to individuals for the treatment of ESRD and for which payment was made separately under this title and any oral equivalent form of such drug or biological– Includes certain drugs formally Part D drugs– Does not include vaccines

• Diagnostic laboratory tests and other items and services not described in clause (i) that are furnished to individuals for the treatment of ESRD


Injectable Drugs used in ESRD Patients

• Epoetin alfa

• Darbepoetin alfa

• Calcitriol

• Doxercalciferol

• Paracalcitdol

• Iron Sucrose

• Sodium Ferric Gluconate

• Levocarnitine

• Alteplase recombinant

• Vancomycin

• Daptomycin

99.7% of all

drugs


Other Drugs used to treat ESRD patients and available in oral form and payable under Part D

• Cincacalcet hydrochloride

• Lanthanum carbonate

• Calcium acetate

• Sevelamer hydrochloride

• Sevelamer carbonate


Payment

Projected 2011 per Treatment Payment $261.58

Prior Case Mix and Geographic Adjustments -56.84

204.74

1% reduction for Outlier Payments -2.05

202.69

2% reduction as Per MIPPA -4.05

Base Payment 198.64

Part D Drug Payment +14.00

Total Payment $212.64

On a Per Treatment basis


Case Mix Adjuster

Case Mix Adjuster Multiplier

New Patient (first 120 days) 1.51

Age

18-44 1.171

45-59 1.013

60-69 1.000

70-79 1.011

80+ 1.016

Body Mass Index (BMI) < 18.5 kg/m2 1.025

Body Surface Area (BSA) per 0.1m2 1.020


Case Mix Adjusters

Acute Case-Mix Adjuster Multiplier

Pericarditis 1.114

Bacterial pneumonia 1.135

Gastro-intestinal bleeding 1.183

Chronic Case Mix Adjuster Multiplier

Hereditary hemolytic or sickle cell anemia 1.072

Myelodysplastic syndrome 1.099

Monoclonal gammopathy 1.024

3


Facility Level Adjustments

• High cost outliers Adjustments for high cost patients, called outlier payments,

to ESRD facilities that treat patients who use more than the predicted amount of

services, including the amount of ESAs. (Projected to be 5.3% of adult

patients).

– Proposing a fixed loss dollar amount of $134.96 for adult and $174.31 for pediatric

dialysis patients. Once the fixed loss dollar amount is met, CMS would pay 80% of the

ESRD facility’s outlier service costs.

• Low-volume facilities

– <3000 treatments in prior year

– Have not opened, closed nor changed provider number due to change in ownership

over past 3 years

• Wage index adjustment using the core-based statistical area definitions based

on most current hospital wage data, rural floor and occupational mix

adjustments and geographic reclassifications.


Beneficiary Coinsurance

The beneficiary coinsurance will be 20% of the ESRD

bundled payment amount, including applicable case mix

adjustments and outlier payments.


The CMS ESRD QIP

Intended to complement the

Prospective Payment System (PPS)

by establishing a financial incentive

for providing high-quality dialysis care.

Instead of payment that asks,

How much did you do?

The Affordable Care Act clearly moves us towards payment that asks,

How well did you do?

and more importantly,

How well did the patient do?

Dr. Don Berwick

CMS Administrator


QIP = Quality Incentive Program

QIP

Penalty


4


Yearly

Averages


“Privileged and Confidential for Quality Improvement Review – Do Not Copy” “Privileged and Confidential for Quality Improvement Review – Do Not Copy”


Changes in Performance Outcomes

2011 Performance Year

(Payment in 2013)

• URR > 65% (weight 50%)

From 96% to 97%

• Hgb > 12 (weight 50%)

From 26% to 14%

Hgb will be rounded to one decimal place

2012 Performance Year

(Payment in 2014)

90% weighted:

• Hgb > 12 (max 30%)

• URR> 65% (max 30%)

• Vascular access type (max 30%)

10% weighted:

• National Health Safety Network Reporting (NHSN) (max 3.3%)

• Patient Experience of Care (IC-CAHPS) (max 3.3%)

• Mineral Metabolism Reporting (max 3.3%)

5


Hemoglobin >12 g/dL

2010

< or = 26% of eligible

patients

2011

< or = 14% of eligible

patients

2012

< or = 4%* of eligible

patients

* 0% is worth a full 30 Points


URR > 65%

2010

> or = 96% of eligible

patients

2011

> or = 97% of eligible

patients

2012

> or = 98%* of eligible

patients

* 100% is worth a full 30 Points


Vascular Access Type (VAT) Measure

� Fistula: > or = 58%* of eligible patient-months

� Catheter: < or = 14%** of eligible patient-months

� Each access measure receives a score

� Final VAT Score: Average score

* 74% is worth a full 30 points ** 5% is worth a full 30 points


Payment Year 2012 vs 2013

2012 Payment Reduction (2010)

Total Performance Score (points)

2013 Payment Reduction (2011)

0% 30 0%

0% 26-29 1.0%

0.5% 21-25 1.5%

1.0% 16-20 2.0%

1.5% 11-15 2.0%

2.0% 0-10 2.0%


6


NHSN Reporting Score


National Health Safety Network

• Requirements: Participating facilities are required to report data according to this protocol, using the NHSN definitions described herein, to ensure data are uniformly reported across participants. A minimum of 6 months of Dialysis Event (DE) surveillance at an outpatient hemodialysis facility, indicated on the Patient Safety Monthly Reporting Plan (CDC 57.106), is required by CDC2. Data must be reported to NHSN within 30 days of the end of the month for which they were collected (e.g., patient census information from September must be reported no later than October 30).

• Dialysis Event: Three types of dialysis events are reported by users: (1) IV antimicrobial start; (2) positive blood culture; and (3) pus, redness, or increased swelling at the vascular access site. An additional four types of dialysis events are calculated from the reported data: bloodstream infection, local access site infection, access-related bloodstream infection, and vascular access infection.

• http://www.cdc.gov/nhsn/dialysis/faq-ESRD-QIP.html


ICH CAHPS Reporting Score


Monthly Mineral Metabolism Reporting

Score


7




8


Operational IssuesResource utilization efficiency

Develop and promote home therapies

Drug and lab utilization

Formulary standardization

Control of oral covered medications

Achievement of clinical quality measures

Adoption of best practices:

Clinical decision support

Protocols

7


Concerns• Did CMS capture all appropriate current lab and drug utilization and

all related costs?

• Are the case mix adjusters correct?

– Cost-relevance

– Readily identifiable by facility

– Lead to Cherry picking

• Establishing appropriate outlier withhold- is the 1% correct? How identified? How calculated?

• Are the Market basket definitions correcdt?

• What will be the payment for Part D drugs?

• Impact of QIP on patient care?

6

Risk that compounded adjustments and penalties threaten facility viability.


Fate of Patients

with low

hemoglobin

values?

Overtreatment of some patients?

Gaming of system to improve

outcomes?Correct timing of samples

Repetitious sampling

Blood Transfusions

Impact on acceptance of

marginal patients-

particularly the elderly?

Duplication of

information

Systems?

Establishing

unimportant clinical

outcomes?

Monitor monthly QIP outcomes.

(Do not bother with trying to figure

the calculations for outcomes.)

How to improve

outcomes in incident

patients?

(Growing role in CKD

Patients)

Monitoring and prevention of Infections and

participate in the National Health Safety Network.

lazarus-the impact of esrd bundling on nephrology...

Documents