Monday, 11 July 2016 04:55

Long-Term Look at Quality Measures in Proposed 2017 ESRD PPS

Written by


The proposed 2017 update to the end-stage renal disease (ESRD) prospective payment system (PPS), which the Centers for Medicare & Medicaid Services (CMS) issued on June 24, 2016, contains revisions to policies and rates for renal dialysis services furnished to beneficiaries on or after January 1, 2017. The PPS includes all renal dialysis services furnished for outpatient maintenance dialysis, including drugs and biologicals (with the exception of oral-only ESRD drugs until 2025) and other renal dialysis items and services that were formerly separately payable under the previous payment methodologies.

Rates Mostly Increase

The proposed 2017 ESRD PPS base rate is $231.04—an increased base rate of $0.65 from the 2016 base rate. CMS projects that the updates for 2017 will increase the total payments to all ESRD facilities by 0.5 percent compared with 2016. For hospital-based ESRD facilities, CMS projects an increase in total payments of 0.7 percent, while for freestanding facilities, the projected increase in total payments will be 0.5 percent.

CMS also proposes to update the outlier services’ fixed dollar loss amounts for adult and pediatric patients and Medicare allowable payments (MAPs) for adult patients for 2017 using 2015 claims data.  By using the more current data, the fixed-dollar loss amount for pediatric beneficiaries would increase from $62.19 to $67.44 and the MAP amount would increase from $39.20 to $39.92, as compared to 2016 values.  For adult beneficiaries, the fixed-dollar loss amount would decrease from $86.97 to $83.00 and the MAP amount would decrease from $50.81 to $47.26. 

Three Years of Quality Measures

In all cases, payment incentives are made to dialysis facilities to improve the quality of care that they provide, and facilities that do not achieve a minimum total performance score (TPS) with respect to quality measures receive a reduction in their payment rates up to 2 percent under the ESRD PPS.

In the proposed 2017 rule, CMS addressed the quality measures for 2018–2020. For 2018, there would be eight clinical measures and three reporting measures encompassing anemia management, dialysis adequacy, vascular access type, patient experience of care, infections, hospital readmissions, and mineral metabolism management.

CMS proposes two substantive changes to the hypercalcemia clinical measure to, as CMS explains, “ensure that the measure remains in alignment with the measure specifications endorsed by the National Quality Forum (NQF).”  These changes involve:

  • Updating the measure’s technical specifications for 2018 and future years to include plasma as an acceptable substrate in addition to serum calcium
  • Changing the denominator definition to include patient-months in the denominator even in the event that a facility reported no calcium values during the three-month study period.

In addition to most of the clinical measures and reporting measures listed above for 2018, the 2019 measures encompass more quality-of-life considerations, which the agency calls a natural “evolution” of the program. Instead of eight clinical measures, there would be seven and instead of three reporting measures there would be five with the following additions: safety, pain management, depression management, and hospital readmissions.

In 2019, a new ultrafiltration rate reporting measure also would be added, and the existing mineral metabolism reporting measure (calculated in part using claims data) would be replaced with a new serum phosphorus reporting measure. A facility’s TPS would be divided into the following:

  • 75 percent to the clinical measure domain
  • 15 percent to the safety measure domain
  • 10 percent to the reporting measure domain.  

In 2020, the total number of measures would increase to 15—eight clinical measures and seven reporting measures, including those above for 2019. Included in the eight clinical measures would be one identified as the standardized hospitalization ratio (SHR). The TPS would be broken down as follows:

  • 80 percent to the clinical measure domain
  • 10 percent to the safety measure domain.
  • 10 percent to the reporting measure domain

Prev Next »

Last modified on Wednesday, 13 July 2016 18:26

Janis keeps the wheel of words rolling for Panacea®'s publishing division. Her roles include researching, writing, and editing newsletters, special reports, and articles for and; coordinating the compliance question of the week; and contributing to the annual book-update process. She has 20 years of experience in topics related to Medicare regulations and compliance.