lazarus-the impact of esrd bundling on nephrology...
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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
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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.
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Patient counts, by modalityFigure p.3 (Volume 2)
Incident & December 31 point prevalent ESRD patients.
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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.
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Government’s bundle objectives
Provide equitable payment
Provide access to services
Promote operational efficiency
Enhance quality of care
Encourage Home Dialysis
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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
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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
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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
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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
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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
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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
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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
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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.
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Beneficiary Coinsurance
The beneficiary coinsurance will be 20% of the ESRD
bundled payment amount, including applicable case mix
adjustments and outlier payments.
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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
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QIP = Quality Incentive Program
QIP
Penalty
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Yearly
Averages
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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%)
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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
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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
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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
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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%
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NHSN Reporting Score
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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
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ICH CAHPS Reporting Score
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Monthly Mineral Metabolism Reporting
Score
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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
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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?
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Risk that compounded adjustments and penalties threaten facility viability.
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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.