WASHINGTON—Under the new end-stage renal disease payment system, the base payment rate for each dialysis treatment will be $229.63, according to the Centers for Medicare & Medicaid Services (CMS).
The new rule (read HERE), which CMS released on July 26, is set to be implemented on Jan. 1, 2011.
The new ESRD payment system is a single bundled case-mix adjusted payment to dialysis facilities for renal dialysis services such as dialysis treatments and supplies, certain ESRD-related drugs, and ESRD-related clinical laboratory tests. CMS currently uses a partial bundle system, which doesn’t include “separately billable drugs,” such as Amgen’s anemia drug Epogen.
The $229.63 payment rate includes payment for the services in the current composite rate, as well as most items and services that are currently paid separately. The base rate was derived from 2007 claims data for both composite rate and separately billable services and updated to reflect projected 2011 prices.
The base payment rate would be adjusted for case-mix factors including patient’s age, body size, and time on dialysis, according to CMS. By accounting for more characteristics of patients, the federal agency said the new payment system "will target payments more appropriately, paying higher rates to those facilities with the most costly dialysis patients."
Separate case-mix adjustments will apply to pediatric patients.
In addition, ESRD-related oral drugs will be included in the new bundle. However, CMS said it has determined the definition of renal dialysis services includes ESRD-related oral drugs without injectable equivalents (or other forms of administration), but that it is delaying paying for those drugs under the ESRD payment system until Jan. 1, 2014.
CMS said it is pushing back the implementation date in order to address data/pricing issues, and to “evaluate and correct any potential concerns that may emerge as a result of the inclusion of the oral drugs and biologicals with other forms of administration in the payment bundle effective January 1, 2011.”
In the final rule, CMS also adopted facility level adjustments including a geographic wage index and an adjustment for low-volume facilities that furnish fewer than 4,000 dialysis treatments and meet certain other criteria. The final rule also includes an outlier payment policy that will pay facilities more for patients whose care is significantly more costly than the Medicare payment amount.
CMS also has reduced the number of case-mix co-morbidity adjustments. In addition, at this time, CMS is not finalizing a case-mix payment adjustment based on the patient’s sex, race or ethnicity. CMS has been reviewing and updating its processes for collecting and validating patient-level race and ethnicity data from dialysis facilities, which will ensure that CMS has the most accurate information possible for the races and ethnicities of all patients with ESRD.
As this work continues, CMS said it will assess whether this effort will position the agency to incorporate such an adjuster for payment in the future. CMS plans to continue studying the issue to ensure that all beneficiaries with ESRD have access to quality care, and in the meantime, plans to implement an active monitoring program to respond to concerns about disparities in access to care.
The new payment system was required by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), which called for Medicare to pay dialysis facilities a single bundled rate for renal dialysis services and home dialysis.
