CMS's latest ESRD/DMEPOS proposed rule helps transition kidney care home
by Jagger Esch
August 16, 2019

In July, the Centers for Medicare & Medicaid Services (CMS) proposed a rule that updates payment rates and policies under the End State Renal Disease (ESRD) Prospective Payment System (PPS) after 2020. Included in this proposal is a suggested update for acute kidney injury dialysis cost for dialysis provided through ESRD facilities.

Additionally, new changes will be made to the ESRD Quality Incentive Program (QIP). Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) will see a reevaluation of the fee schedule.

These changes should be finalized in late October. The rule is expected to have little to no changes before finalization.

New Home Dialysis Treatment Options

In response to the CMS proposal, companies such as Baxter, DaVita, CVS and Fresenius have announced plans for enhancing home dialysis options. This service comes from a July executive order that encourages modernizing American kidney care by moving patients away from in-center dialysis.

These companies are investing big money to progress towards quality in-home dialysis services.

Baxter has stated it will invest about $500 million towards its renal care manufacturing capacity. The German company Fresenius reports its plan to invest roughly $111 million.

Over 36 million adult Americans suffer from some form of kidney disease—approximately 15% of adults in the United States. In 2017, kidney disease was the ninth leading cause of death in the U.S.

Even though these numbers are high, the health care available has remained relatively the same since the 1982 Medicare law was set by President Ronald Regan. Medicare is spending approximately $114 billion each year on kidney disease.

Researchers believe it will be more cost-effective to transition dialysis to home health sites and move it away from community-based acute facilities. Currently, 12% of Americans receive in-home dialysis treatment; the aim is for 80% to receive in-home care.

Trump Issues Executive Order for Better Kidney Care in the United States

President Donald Trump wants to revamp kidney disease treatment in America. This will be done with innovation and new payment models, and an emphasis on the importance of improving quality care metrics.

The policy has three major goals:

  1. Reduce the number of beneficiaries with end-stage renal disease by increasing preventive care.
  2. Incentivize the use of home dialysis and cut the costs associated with high-cost dialysis centers.
  3. Increase the number of transplants available by encouraging artificial and wearable kidneys; also, modernizing the organ transplantation and recovery system.

This executive order also calls for the Department of Health and Human Services (HHS) to improve monetary support for any living donors; this includes family or friend donors, and donors simply giving into the system.

Monetary support will include lost wages, transportation, childcare and any other related costs that would otherwise be a barrier for kidney donors.

Adjusting the DMEPOS Fee Schedule

In addition to the changes being made to the ESRD services, the DMEPOS fee schedule will see some changes. Basically, the adjustments are established using commercial and supplier prices.

This new rule will make amendments to review current policies related to competitive bidding for DMEPOS. Also, beneficiaries will notice the streamlining of requirements for ordering DMEPOS supplies.

A DMEPOS master list would state items that could be subjected to face-to-face encounters, prior authorization requirements or written orders before delivery.

Lastly, the master list would include requests for information on possible updates to the ESRD PPS wages index.

ESRD PPS Base Rate Update

The calendar year 2020 ESRD PPS proposed base rate is $240.27; this is an increase of $5 to the current base rate of $235.27. This proposed amount reflects implementation of the act.

The rule should provide transparency for any innovators looking to determine how CMS compares new items to older ones for prices. Additionally, this proposal encourages competition and innovation with DMEPOS by implementing commercial pricing data for new items.

Modernizing the payment schedule ensures taxpayers receive the best deals. These changes are a response to the concerns of stakeholders; facilities will spend less time reviewing policies and more time concerned with providing a higher quality of care.

Competitive bidding will also apply to diabetic testing supplies.

Other 2020 CMS Updates and Important Information

CMS will update the 2020 Medicare Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgical Payment System. Additionally, the Medicare Physician Fee Schedule and Quality Payment Program (QPP) of 2020 will see an update.

These changes are the result of the president’s executive order on quality and price transparency. The intention is to lay the foundation for a patient-focused health care system.

This proposal will apply to renal dialysis equipment authorized by the FDA in 2020; the extra cost will take place over two years and would be determined based on 65% of the price Medicare Administrative Contractors establish.

CMS also intends on making updates to regulations so that it better informs people about program requirements. Feedback for the PPS must be sent by Sept. 27 of this year.

The CMS encourages the public to comment on the proposal before the close of the comment period. All posts are public and submitted via regulations.gov.

These changes should provide beneficiaries with lower copayments. In 2020, savings for the Medicare program and taxpayers should be approximately $810 million.