CMS Releases ESRD Prospective Payment Service Final Rule

November 18, 2011

On Thursday, November 10, 2011, 72 F.R. 70228, the Centers for Medicare and Medicaid Services (CMS) issued a final rule (Final Rule) regarding the End-Stage Renal Disease (ESRD) prospective payment system (PPS) and the ESRD Quality Initiative Program (QIP). In the Final Rule, CMS:

  1. Establishes an ESRD PPS base rate of $234.81 for calendar year (CY) 2012. The new base rate represents a 2.1% increase over CY 2011 (composed of a 3% increase in the market basket and a 0.9% wage index budget-neutrality adjustment that was mandated by the Affordable Care Act of 2010).
  1. Updates the composite rate portion of the blended payment to $141.94. CMS will continue to update the composite rate through the four-year transition period established by the ESRD PPS for CY 2011, which ends in 2013.
  1. Sets forth requirements for the QIP for payment years (PY) 2013 and 2014. CMS will retire one performance measure for PY 2013, i.e., the anemia management measure of hemoglobin level less than 10g/dL. CMS notes that this elimination is in keeping with its reassessment of the use of erythropoiesis stimulating agents in patients with kidney disease. Thus, the QIP will account for only two measures in 2013: dialysis adequacy, as measured by the urea reduction ratio (URR), and anemia management, as measured by the percentage of patients with a hemoglobin level greater than 12g/dL. The performance period for PY 2013 will be CY 2011. Performance in CY 2011 will be scored by comparing CY 2011 claims data against the initial performance standard, which will be the lesser of the provider/facility’s performance during 2007 or the 2009 national performance rates. In PY 2014, CMS will adopt four additional QIP measures. The performance period for PY 2014 will be CY 2012. The six measures that will be used in 2014 are:
    1. Dialysis adequacy, as measured through the URR, which assesses the percentage of patients with a URR of at least 65%.
    2. Anemia management, as measured by the percentage of patients with a hemoglobin level greater than 12g/dL.
  2. The average of the measures of the percentage of patients receiving treatment through an arteriovenous fistula and the percentage of patients receiving treatment through a catheter.
  3. Whether the facility reports certain dialysis-related infections to the Centers for Disease Control & Prevention’s National Healthcare Safety Network.
  4. Whether the facility administers a patient experience of care survey.
  5. Whether the facility monitors phosphorus and calcium levels on a monthly basis.

Finally, the Final Rule includes several provisions that are not related to the ESRD PPS and QIP. These provisions relate to payment for ground ambulance services and certain rural area designations for purposes of air ambulance payment, and the lifetime requirement for equipment to be considered durable for purposes of coverage as durable medical equipment.