CMS bumps ESRD facility payments by 2.1%

Photo: Science Photo Library/Getty Images

In a final rule, the Centers for Medicare and Medicaid Services is increasing the end-stage renal disease (ESRD) prospective payment system (PPS) base rate to $271.02, thus increasing total payments to ESRD facilities by about 2.1% in an update to payment rates and policies regarding renal dialysis services furnished to Medicare beneficiaries on or after January 1.

The rule also updates the acute kidney injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities for 2024, and updates requirements for the ESRD Quality Incentive Program (QIP).

The CY 2024 ESRD PPS final rule also includes several changes related to ESRD PPS payment policies. First, this rule includes a payment adjustment that will increase payment for certain new renal dialysis drugs and biological products after the Transitional Drug Add-on Payment Adjustment (TDAPA) period ends. This increase, said CMS, will help ensure payment is not a barrier to accessing treatments for Medicare ESRD beneficiaries.

On top of that, the rule includes new requirements, effective January 1, 2025, for reporting on ESRD PPS claims, of "time on machine" data – that is, the amount of time that a beneficiary spends receiving in-center hemodialysis treatment – and for reporting of discarded amounts of certain renal dialysis drugs and biological products from single-dose containers and single-use packages.

The rule also finalizes a new transitional add-on pediatric ESRD dialysis payment adjustment for calendar years 2024, 2025 and 2026. This is expected to promote equitable and accurate payments, since treatment for the pediatric ESRD population tends to be especially complex and costly, according to CMS.

Additionally, the CY 2024 ESRD PPS final rule discusses responses to the requests for information issued in the proposed rule to inform potential future rulemaking regarding updates to the low-volume payment adjustment (LVPA) methodology, and the possible creation of a new payment adjustment that would increase payment to geographically isolated ESRD facilities.

The rule also finalizes certain exceptions to the LVPA attestation process for ESRD facilities affected by disasters and other emergencies.

WHAT'S THE IMPACT?

The ESRD PPS provides a bundled, per-treatment payment to ESRD facilities that includes all renal dialysis services furnished for outpatient maintenance dialysis, including drugs and biological products (with the exception of oral-only ESRD drugs until 2025). Additionally, the bundled payment includes all other renal dialysis items and services that were formerly separately payable under previous payment methods.

The bundled payment rate is case-mix adjusted for a number of factors relating to patient characteristics. There are also facility-level adjustments for ESRD facilities that have a low patient volume, for facilities in rural areas and for the wage index. When applicable, the bundled payment rate also includes a training add-on payment adjustment for home and self-dialysis modalities, an outlier payment for high-cost patients, and add-on payment adjustments for certain drugs, equipment and supplies.

CMS projects that the updates for CY 2024 will increase the total payments to all ESRD facilities by 2.1% compared with CY 2023. The agency also projects an increase in total payments of 3.1% for hospital-based ESRD facilities, and an increase in total payments of 2.0% for freestanding ESRD facilities.

For CY 2024, CMS is creating an exception to the current LVPA attestation process for ESRD facilities affected by disasters and other emergencies. Specifically, CMS is establishing an exception process that will allow ESRD facilities to close temporarily and reopen in response to a disaster or other emergency and still receive the LVPA.

Additionally, CMS will allow a facility to continue to receive the LVPA, even if it exceeds the LVPA threshold if its treatment counts increase due to treating additional patients displaced by a disaster or other emergency.

To assess the alignment of resource use with payment, particularly for subpopulations of ESRD beneficiaries that may require higher-than-average resource use, effective January 1, 2025, CMS will require ESRD facilities to report on ESRD PPS claims, the "time on machine," which is the amount of time in minutes that a beneficiary spends receiving in-center hemodialysis treatment. CMS said it will use this time on machine data to more precisely estimate dialysis treatment costs for the purposes of considering future refinements to the ESRD PPS adjustment factors.

CMS has recently begun to gather additional cost report data about costs involved in furnishing renal dialysis services to pediatric ESRD patients. Based on the current data, CMS estimates that pediatric patients incur higher resource use than average adult dialysis patients. 

To address equity concerns about access for pediatric beneficiaries with ESRD, the agency is finalizing a new transitional pediatric ESRD add-on payment adjustment (TPEAPA) of 30% of the per-treatment payment amount. This adjustment will apply to all ESRD PPS payments for renal dialysis services furnished to pediatric ESRD patients and will apply for a period of three years (calendar years 2024, 2025 and 2026) beginning January 1, 2024, while CMS collects additional data from cost reports to evaluate the alignment of resource use by pediatric ESRD patients with payment.

FINALIZED POLICIES FOR PAYMENT YEARS 2026 and 2027

CMS is finalizing its proposal to add the Facility Commitment to Health Equity reporting measure to the ESRD QIP measure set, beginning with payment year (PY) 2026. This measure, which CMS first adopted for use in the Hospital Inpatient Quality Reporting (IQR) Program in the FY 2023 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) final rule, assesses an ESRD facility's commitment to health equity based on its responses to five equity related attestation-based questions.

The agency is also finalizing its proposal to update the COVID-19 Vaccination Coverage Rate Among Healthcare Personnel (HCP) reporting measure beginning with PY 2026 to align with updated measure specifications developed by the CDC. The update reflects the status of COVID-19 transmission in the U.S., recommendations from the CDC and FDA that eligible individuals be up to date on their vaccinations and real-world data demonstrating vaccine efficacy.

CMS is finalizing its proposal to convert the Clinical Depression Screening and Follow-Up reporting measure to a clinical measure, beginning with PY 2026. CMS is also finalizing its proposal to update the scoring methodology so that the measure is better aligned with current clinical guidelines for depression screening and follow-up.

It's also finalizing its proposal to remove the Ultrafiltration Rate reporting measure from the ESRD QIP measure set beginning with PY 2026. CMS is removing this measure from the program measure set under measure removal factor two (Performance or improvement on a measure does not result in better or the intended patient outcomes.), because documentation of a patient's ultrafiltration rate through the current measure may not indicate the quality of a patient's ESRD treatment. Because of that, a facility's performance on the measure may not accurately reflect the quality of care provided, the agency said.

And CMS is finalizing its proposal to remove the Standardized Fistula Rate clinical measure from the ESRD QIP measure set, beginning with PY 2026. CMS is removing this measure from the program measure set under measure removal factor three (A measure no longer aligns with current clinical guidelines or practice.), because updated vascular access treatment guidelines indicate a preference toward increased flexibility in the choice of arteriovenous (AV) access (either AV fistula or AV graft), where appropriate, and urge providers to consider what would be most appropriate for the individual patient.

THE LARGER TREND

For 2027, CMS is finalizing its proposal to add the Screening for Social Drivers of Health reporting measure to the ESRD QIP measure set. This health-equity-related measure, which the agency first adopted for use in the Hospital IQR Program in the FY 2023 IPPS/LTCH PPS final rule, assesses the percent of patients 18 and older screened for food insecurity, housing instability, transportation problems, utility help needs and interpersonal safety.

CMS is finalizing its proposal to add the Screen Positive Rate for Social Drivers of Health reporting measure to the ESRD QIP measure set, beginning with PY 2027. This health-equity-related measure, which was first adopted for use in the Hospital IQR Program in the FY 2023 IPPS/LTCH PPS final rule, assesses the percentage of patients 18 and older who screen positive for one or more of the five listed health-related social needs.

Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com