On Friday, October 31, the Centers for Medicare & Medicaid Services (CMS) issued final regulations regarding payments to dialysis facilities and quality measures dialysis facilities must meet in 2017 and 2018 to avoid facing a penalty.
In summary, CMS will increase the base amount that facilities get paid by $0.41, but rural facilities will see a small cut in their payments as a result of overall payment changes designed to better align payment with the updated costs of providing the care. CMS will also make changes to the quality measurements outlined in the Quality Incentive Program (QIP). The goal of the new measures in the QIP is to encourage dialysis facilities to communicate and coordinate with the patient’s entire healthcare team, and to improve upon the level of attention and care the staff gives to patients.
Dialysis Payment Changes
With the ruling, CMS’s Medicare payments remain relatively flat, with rural facilities seeing a slight cut to payments and urban facilities receiving a slight increase. The National Kidney Foundation (NKF) had requested CMS spread its changes out over two years so the entire cut to rural facilities does not hit at one time. CMS agreed and Medicare payments to rural facilities will be roughly half a percent this year and half a percent next year. CMS stated they will consider further changes to payments in next year’s rulemaking, which is expected to begin in July or August 2015.
NKF continues to remain concerned that dialysis facilities in rural areas will remain at high risk for closure because many rural facilities lose money treating Medicare patients (some rural facilities overwhelmingly consist of Medicare patients). Closures in rural areas put dialysis patients’ health and life at greater risk because they may face transportation challenges if they have to commute further to receive dialysis and see their nephrologists. NKF will continue to speak with CMS officials about our concerns and suggestions in advance of next year’s rulemaking.
Quality Incentive Program
CMS made many favorable changes to the ESRD QIP for years 2017 and 2018. In 2017, dialysis facilities will be evaluated on a new measure based on the total number of patients and the number of times that patients in a facility are re-admitted to the hospital. NKF supports this measure as we believe it will encourage dialysis facilities and hospitals to better coordinate care for dialysis patients after they have been discharged from the hospital. NKF had recommended that CMS tailor the measure to only include reasons for readmission that are within the nephrologist’s and dialysis facility’s staff to control. However, CMS disagreed and stated facilities could have an impact on reducing hospital readmissions overall if they improved communication with the hospital and if a physician, which could include the dialysis facility’s chief medical officer, saw a patient immediately after he or she was discharged from the hospital.
CMS will also remove the anemia management measure of hemoglobin greater than 12g/dl because very few facilities have patients who are being treated for anemia with hemoglobin levels above 12g/d. NKF supported removing this measure.
In 2017, the QIP will assess and measure dialysis facilities based on:
- Patients who receive adequate dialysis (measured by Kt/V)
- Patients with a fistula
- Patients with a catheter for more than 90 days
- Patients with hypercalcemia
- Patients who have had bloodstream infections during the year
- Patients who have been readmitted to the hospital within 30 days of the initial discharge
- Reporting of results from the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Services (ICH CAHPS)
- Reporting of patients’ phosphorus levels
- Reporting of patients’ hemoglobin levels and dose of erythropoietin stimulating agents (ESA)
In 2018, CMS will also hold dialysis facilities accountable for their patients’ satisfaction and require that facilities report how they have evaluated patients for depression and pain. If depression and pain are identified, facilities must document a follow-up plan to address a patient’s needs. NKF supports these patient-centered measures. We believe these measures will encourage dialysis facility staff and nephrologists to improve upon their attentiveness and communication with patients. This increased focus will not only lead to patients having a better experience with their dialysis care, but may lead to faster detection of other health conditions, improved communication and coordination with the other healthcare practitioners and ultimately better individualized treatment for patients.
In addition, CMS will penalize facilities if they have too many patients receiving blood transfusions. NKF supports this measure as it will ensure that facilities are paying closer attention to managing dialysis patients’ anemia through proper dosing of ESAs and iron. Blood transfusions can have unintended consequences for some patients, including making it more difficult for some to get a kidney transplant.
In 2018, the QIP will assess and measure dialysis facilities based on:
- Patients who receive adequate dialysis (measured by Kt/V)
- Patients with a fistula
- Patients with a catheter for more than 90 days
- Patients with hypercalcemia
- Patients who have had bloodstream infections during the year
- Patients who have been readmitted to the hospital within 30 days of the initial discharge
- Performance on patient satisfaction (measured by responses on certain questions from the ICH CAHPS)
- Patients who received blood transfusions during the year
- Reporting of patients’ phosphorus levels
- Reporting of patients’ hemoglobin levels and dose of erythropoietin stimulating agents (ESA)
- Reporting on the percent of patients that have been screened for depression and have a follow up plan documented
- Reporting on the percent of patients who have been assessed for pain during each visit and who have a follow up plan documented when pain is discovered
Comment and let us know what you think about the new changes. Do you live in a rural area with limited dialysis choices? Do you agree with the QIP and how CMS plans to measure dialysis facilities in the future? If you could design one quality measure for dialysis facilities, what would it be?
Advocacy in Action 
I think patients in a rural setting will be screened more heavily for home dialysis choices, which in genetal should lead to better health. The only thing that is of concern is how involved the nephrology docs are willing to be with taking charge of pain control. Many have gotten away from the general “PMD” treatment and focusing on dialysis related concerns as it relates to giving prescriptions for pain meds. Also, depression screening and treatment in the facilities needs lots of work: I feel the addition of “counselors” for this will improve the treatment and there needs to be case workers for managing other social concerns.
I live and work in rural area. The cuts to rural clinics will have devastating effects. These people already can’t get to the MD or clinic and now we will be “punished” because of geography. This needs rethinking. These people need the care the most.
I agree. My dialysis facility is in a rural area and most patients would not be able to receive treatment if it were to close because of financial constraints imposed by Medicare.
I agree with all the changes being made by CMS, especially as a dialysis patient who gets her care in a small private facility. My only concern where I am is that we don’t have a dietician at the moment ( we have been without one since September) And it’s been three months since I have seen a Nephrologists ( and not do to lack of transportation ). Also I am afraid that administration is bringing in too many patients with very little space. One of the reasons I left Davita was because there are too many patients. I believe these changes that CMS is implementing will be great but also agree that there is room for more improvements.
I don’t read these changes to require the Nephrologists to manage chronic pain, but to acknowledge it and facilitate getting the patient to the appropriate provider. We would benefit from more consistent practices in terms of delivery of primary care –I think most would agree that the dialysis clinics are NOT primary care facilities. PCP involvement in the care of people on dialysis is highly varied and needs to be recognized as a very necessary piece to patient care.
I’m a dialysis patient who suffers from sometimes debilitating pain. The staff at my facility knows this, my nephrologist and primary care physician know this, but no one has ever found a solution to help me.
All dialysis centers have to cut corners to the point of bare bones care for every measurement, it seems to me. Wish the CEO ‘s pay would be printed at the top of each page of the satisfaction questionnaires of patients and employees of dialysis centers and for every point it is lowered about a million dollars of their pay be ‘re-invested in quality care. Unappreciated employees don’t care very much about their patients when they themselves are so unhappy. Patients are at the mercy of employees and attitudes are transmitted so very quickly.
Patients don’t expect luxuries, but watching the basics degrade over time is surely dishearting.
What they should be looking at is the fact that units are running unsafe due to shorten staff and more patient, I have been a tech for over 2yrs and love my job however pts are being hearded in and out and the management is only making it worse. This is a serious service that is provided and big companies like Davita and FMC would cut out half the middle management they could pay for better and more experience staff. They’re greedy and the pts are the one paying the price for it.
As well as staff is working with 5-8 pts 2 and 3 shift per day 15 .and 18th shifts so yeah they be grumpy and tired that’s what needs to be addressed
Apparently, getting older or becoming disabled is a measurement stick to Medicare that you don’t deserve basic medical care in rural settings. Many of us are retired in a rural setting as it costs less to live here. Now we are being punished for being ill and living in the wrong place. I wish my government cared as much for me as it does for countries around the world who have NOT paid taxes for 50 years like we have. This is unconscionable behavior!