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2020 ESRD PPS: Insights into Proposed Changes

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13 Sep 2020 ESRD PPS: Insights into Proposed Changes

CMS is offering an increased rate per dialysis treatment and a bonus to providers if they use newer technology in their clinics in a proposed rule for the Prospective Payment System released on July 29, 2019.

 

The agency also included changes in that rule, which would be effective in January 2020, to the Quality Incentive Program (QIP), a set of quality measures used by CMS to monitor the performance of clinics. In a separate rule, CMS released the Medicare Physician Fee Schedule, which sets the guidelines for physician payment for Medicare patients, including those with ESKD. Both proposals have 60-day comment periods; feedback for the Prospective Payment System (PPS) rule is due September 27, 2019 and can be sent via regulations.gov.

 

The proposed rule for dialysis facilities comes under the PPS, a bundled payment that includes all renal dialysis services furnished for outpatient dialysis including drugs and biological products (with the exception of oral-only ESRD drugs until 2025). The payment rate, which also applies for patients treated with acute kidney injury, is casemix adjusted for a number of factors relating to patient characteristics. The ESKD PPS provides a training add-on payment adjustment for home and self-dialysis modalities and, for high-cost patients, an ESRD facility may be eligible for outlier payments. The ESRD PPS also provides for a transitional drug add-on payment adjustment (TDAPA).

Synopsis

  • Update to the ESRD PPS base rate for CY 2020: the proposed CY 2020 ESRD PPS base rate is $240.27
  • Proposal to change the basis of payment for the TDAPA for calcimimetics: continuing to pay the TDAPA for calcimimetics for a third year in CY 2020 in order to collect sufficient claims data for rate setting analysis, but are proposing to reduce the basis of payment for the TDAPA for calcimimetics for CY 2020 from the average sales price plus 6 percent (ASP+6) methodology to 100 percent of ASP
  • New and innovative renal dialysis equipment and supplies under the ESRD PPS
  • Changes to the QIP

References

https://www.cms.gov/newsroom/fact-sheets/end-stage-renal-disease-esrd-and-durable-medical-equipment-prosthetics-orthotics-and-supplies-dmepos

 

https://www.federalregister.gov/documents/2019/08/06/2019-16369/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis