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Payment and Measuring Quality: Next
Steps for the ESRD Program
Florida Renal Administrators
Association
42nd Annual Meeting
July 18, 2015
The ESRD Program: 1972-2015
Payment
• composite rate
• monthly capitated payment
• the Prospective Payment System (the bundle)
• Accountable Care Organizations (ESCOs)
• sustainable growth rate
Fee Schedule and pay-for-performance
What we will cover: 1972-2015
Quality
• Conditions of Coverage
• Core Survey
• Quality Incentive Program
• Five-Star Ratings
What could we do to help
dialysis and transplant care
with
1.425 billion?
Legal settlements between dialysis providers and the
federal government
2000: $486 million
FMC settles fraud and criminal charges; Employees indicted
2012: $55 million
DaVita settles charges of using EPO overfill
2014: $389 million
DaVita settles anti-kickback charges with physicians practices
2015: $495 million
DaVita settles charges over excessive use of iron and Vitamin D.
1.425 billion!
"I think our overwhelming feelings about this—forget the
thoughts—are just we're very disappointed in ourselves and
really humbled by the fact that we are having to write a check
this big… this is not how we ever envisioned ourselves
spending time or your (investors) money.
We did make some mistakes and we're accountable for that.”
–– DaVita Healthcare CEO Kent Thiry
"We should be held to high standards of accountability. Our
67,000 teammates across 11 countries look forward to putting
this behind us. We can now renew our focus on collaborating
with regulators to avoid situations like this going forward.”
–– DaVita Kidney Care CEO Javier Rodriguez
History of politics and dialysis
November 4, 1971:
Shep Glazier, VP of the National Association of Patients on
Hemodialysis, dialyzes on the floor of Congress
“I am going to tell the [House Ways and Means] Committee that if
dialysis can be performed on the floor of Congress, it can be
performed anywhere. Kidney patients don’t have to be confined to
hospitals, where expenses are $25,000 a year and more per patient.
It’s much cheaper in a satellite unit or at home. I want to show the
Committee what dialysis is really like. I want them to remember us.”
-- Addressing the media
History of politics and dialysis
1972:
• Original cost estimate: $250 million a year, “and most of that will be
recovered as patients return to productive lives.”
• By 1979: $1 billion,
• By 1990: $5 billion
• By 1998: $12.3 billion
NOW: $16 billion
Developing a payment system
1982:
Payment and new regulations
1976: Conditions of Coverage released (updated again in 2006)
(starting to look at it again in 2015)
1978: CMS pays for home patients on day one and eliminates
the 90-day delay (still applicable to in-center patients).
1983: Monthly capitated payment set for physicians
1989: Cost for Epogen covered by Medicare
.
Payment and new regulations
2000: Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act (BIPA)
- Congress required the Secretary to issue a report on a
bundled system that would include separately billable drugs
and clinical laboratory services routinely used in furnishing
dialysis.
2003: “Toward a Bundled Outpatient Medicare End Stage Renal
Disease Prospective Payment System,” released.
.
Developing a (new) payment system
2003: The Medicare Prescription Drug, Improvement, and
Modernization Act (MMA), Public Law 108-173
- Required the Secretary to submit to the Congress a report detailing
the elements and features for the design and implementation of a
bundled ESRD PPS. Section 623(f)(1) of the MMA specified that such
a system should include the bundling of separately billed drugs,
clinical laboratory tests, and other items “to the maximum extent
feasible.” Section 623(e) of the MMA also REQUIRED a
demonstration project testing the feasibility of using a fully bundled
case-mix adjusted ESRD PPS.
Developing a (new) payment system
2011: Prospective Payment System takes effect
- demonstration project? (Didn’t happen.)
BUT…over 90% of clinics
agreed to accepted the bundled payment
In January 2011 (offered a blended rate)
Why?
• favorable drug payment (even with 2% overall cut)
• yearly market basket review
Renal ACO demonstration
Each applicant builds an ESCO
(ESRD Seamless Care Organization)
Integrated care: Hub-and-spoke approach
Hub: nephrologists
Spokes: Endocrinologists, cardiologists,
psychiatrists, vascular surgeons, cancer
specialists
LAUNCH: JULY 2015 (we think…)
New Payment Models for ESRD
• CMS wants to promote coordination of
care, decrease hospitalizations and ER
visits, and decrease overall costs of ESRD
• Current silos of payment (Medicare parts
A, B, and D) and of care (dialysis facilities,
hospitals, extended care facilities) do not
align incentives
• End-stage renal disease seamless care
organizations (ESCOs) are one approach
For Physicians Only
The “New” Sustainable Growth Rate
• Congress wrestled each year with a 21% cut in Medicare physician pay triggered
by the SGR.
• Finally got enough votes to “kill it” in 2015.
What new payment model does:
• eliminated the SGR, physicians will get a modest payment increase of 0.5% this
year and for the next three years.
• Beneficiaries are expected to see a $100 million reduction in out-of-pocket costs.
• Starting in 2019, doctors who have at least 25% of their patients in value-based
payment models eligible for 5% bonus payments through 2024. After that:
annual payment bumps of 0.75%, three times the level of increase for
physicians that remain on the fee-for-service track.
The Quality Incentive Program 2015-2018
• Discussion continues on tying in hospitalization, morbidity and
mortality data. Includes measures dealing with pain
management, depression in the future
New Developments
• Kidney Care Partners’ “A Strategic Blueprint for Advancing Kidney Care
Quality”
Identify key areas for advancing improvement in kidney care.
Four patient-centric goals
•
Improve patient survival
•
Reduce hospitalizations
•
Improve health-related quality of life
•
Improve patient experiences with care
Fluid Management a top priority for a Clinical Performance Measure
ESRD QIP
National Priorities
ESRD QIP
Performance Year vs. Payment Year
Performance Year
2010
2011
2012
2013
2014
2015
2016
Payment Year
2012
2013
2014
2015
2016
2017
2018
QIP Measures PY 2012-15
Measure
2012
2013
2014
2015
Hb <10
Yes
Hb >12
Yes
Yes
Yes
Yes
URR >65%
Yes
Yes
Yes
Kt/V >1.2
Yes
High AVF
Yes
Yes
Low CVC >90 d
Yes
Yes
Pediatric HD adequacy
Yes
PD adequacy
Yes
ICH-CAHPS administration
Yes
NHSN reporting of infections
Yes
Anemia reporting
Yes
Mineral metabolism reporting
Yes
QIP Measures PY 2016
Clinical Measures
• Anemia Management: Hgb > 12
• Hemodialysis Adequacy: Minimum delivered
hemodialysis dose
• NHSN Bloodstream Infection Monitoring
• Peritoneal Dialysis Adequacy: Delivered dose above
minimum
• Pediatric Hemodialysis Adequacy: Minimum spKt/V
• Vascular Access Type: Arterial Venous (AV) Fistula
• Vascular Access Type: Catheter >= 90 days
• Hypercalcemia
QIP Measures PY 2016
Reporting Measures
•Anemia Management Reporting
•ICH CAHPS Administration
•Mineral Metabolism Reporting
QIP Measures PY 2018
• Clinical Measures:
• NHSN Bloodstream Infection in Hemodialysis Outpatients
• Standardized Readmission Ratio
• Hemodialysis Adequacy: Minimum delivered hemodialysis
dose
• Peritoneal Dialysis Adequacy: Delivered dose above
minimum
• Pediatric Hemodialysis Adequacy: Minimum spKt/V
• Vascular Access Type: Arterial Venous (AV) Fistula
• Vascular Access Type: Catheter >= 90 days
• Hypercalcemia
• ICH CAHPS Patient Experience of Care
• Standardized Transfusion Ratio
• Pediatric Peritoneal Dialysis Adequacy: Delivered dose
above minimum
QIP Measures PY 2018
• Reporting Measures:
•
•
•
•
•
Mineral Metabolism Reporting
Anemia Management Reporting
Pain Assessment and Follow-Up
Clinical Depression Screening and Follow-Up
NHSN Healthcare Personnel Influenza
Vaccination
Five-Star Rating System
• Based on data from the
Dialysis Facility Compare website
• Providers don’t like the “bell curve”
methodology that forces clinics into certain
star ratings
• No real accounting for acuity of patients,
location of facility
• Confusing verbiage from CMS about how
patients should use the stars
Five-Star Rating System: The Arizona Test
• comparison of three dialysis clinics in Scottsdale:
• a one star, three star, and a four-star clinic.
-All were within 20 miles of my location.
What Dialysis Facility Compare and Five Star said:
(3/3) hospital admission and hospital readmission rates
“as expected.”
(2/3) The three-star and four-star facilities also had
mortality rates as expected.
The one star clinic had a mortality rate “worse than
expected,” according to the profile. But it’s not clear how
much: if 1.00 is “as expected,” was this clinic 1.03? The
data isn’t provided.
Five-Star Rating System: The Arizona Test
Clinical measures: Kt/V, dialyzing with a fistula, patients with
hypercalcemia (calcium >10.2 mg/dl).
In a side-by-side comparison of these three clinics the four-star clinic did
better in several categories – but not always by much.
• The one-star clinic had 94% of its patients with a Kt/V greater than 1.2;
the four-star clinic had 95% of its patients hit that quality measure.
• Both the one-star and the four-star clinic had no patients with
hypercalcemia.
• But the one-star clinic did have more patients with catheters (57% vs.
74%) and 26% of its patients still had catheters after 90 days (v. 9% for
the four-star clinic).
• And that one-star clinic did have a higher mortality rate, although we
don’t know how much. So those differences in criteria made the
difference in the star ratings.
Other Hot Topics
• Dialyzing at (nursing) home
CMS may be preparing new regs for home,
including dialysis inside a nursing home
- Not much regulation now
• Outcomes are improving when clinics dialyze
inside the nursing home vs. sending patients
to the clinic.
Other Hot Topics
PD fluid shortage
“The Baxter shortage has been a real challenge to the entire health care community.
The late decision to maintain a rationing of cycler solution beyond the first quarter
timetable set by Baxter and discontinuing the Irish importation despite the FDA
view that a solution shortage still existed caught physicians and patients off guard.
The potential for future Baxter shortages for other components of PD has also raised
concerns.
“At this time we do not have a clear answer from Baxter as to when things will be back
to supply levels which will support growth or whether Baxter will move to shrink
their footprint in the U.S. in favor of overseas market expansion.”
Martin Schreiber, MD,
Vice President of Clinical Affairs, Home Modalities, DaVita Kidney Care
ESRD Drug Pipeline
• Keryx
- ferric citrate approved Sept. 5, 2014
-
binds phosphorus, reduces iron, EPO needs
• Rockwell
Triferic approved January 24, 2015
soluble ferric pyrophosphate citrate
(Two new studies show it replaces iron loss, maintains hemoglobin, and
does not increase iron stores. A smaller study published inline July 8 in
Kidney International found similar results.
…and Beyond
ESAs coming from
• Fibrogen
• Akebia
• GlaxoSmithKline
• Roche
• Hospira
…and Beyond
• Relypsa
“A year-long study of more than 300 patients with
hyperkalemia, hypertension, type 2 diabetes, and chronic
kidney disease found that the investigational drug Patiromer
can reduce elevated blood-potassium levels.
The drug, given in this trial at one of four doses based on disease
severity, returned blood potassium levels to normal when
measured at four weeks and kept them under control for one
year, the length of the trial.
Payment and Measuring Quality: Next
Steps for the ESRD Program
Florida Renal Administrators
Association
42nd Annual Meeting
July 18, 2015
NN&I Resources
• Mark Neumann ([email protected])
• Thrice-weekly eNews
Subscribe at www.nephrologynews.com, click on “eNews” tab
Special Topics
QIP: www.nephrologynews.com/qip
ACO/ESRD demonstration: www.nephrologynews.com/aco
Bundled payment: www.nephrologynews.com/esrd-bundle
CMO Initiative: www.nephrologynews.com/cmo