Welcome to the new Newsletter format

In the past couple decades QMS has produced a newsletter for our clients and interested parties in the dialysis community and sent it out via ground mail. We have decided to modify that process for efficiency, speed of delivery, and more effective access to our client base. So welcome to our new E-Newsletter.

We have also added to our approach. In the past, the Newsletter was composed of articles dealing with current challenges to the dialysis industry as well as relevant areas of QMS effort that would be of interest. With this new initiative we are also including calendar items (e.g., QMS Users' Meeting and opportunities to interact and register a request (e.g., make sure you will receive one of our annual Calendars)

U.S. End Stage Renal Disease (ESRD) program is facing challenges
by John Sargent

The US End Stage Renal Disease (ESRD) program is facing challenges into the future – both strategic and immediate. Although US healthcare overall is undergoing exhaustive review, to which the ESRD program is just a small part, there are several issues which have resulted in changes to this program:

• ESRD is a disproportionately large percentage of the Medicare budget.
• Clinical outcomes for ESRD patients continue to be “poor”.
• A patient with newly diagnosed colon cancer has a better life expectancy than a newly diagnosed patient with ESRD. Outside observers are asking “why”?
• Vascular access in the US costs $ 2.0 billion annually, driving outside agencies to require specific reporting, specific protocols, and monitoring. Vascular access is expected to be a target of pay for performance initiatives.
• Seventy percent (70%) of dialysis patients have cardiovascular disease and left ventricular hypertrophy. Inadequate fluid management is widely viewed as a silent and secret killer in dialysis.
• Anemia management through the use of EPO has become a target of payors.

This collection of issues appear to be part of the thrust of bundling and toward increased national reporting (read CROWNWeb), pay for performance, etc. In addition to addressing these issues, QMS is also engaged in the immediate concerns of continuing to comply with on-going regulation changes as well as adopting our systems to assure that our clients collect 100% of what is due to them for the services they provide. We are being active in addressing these challenges – both strategic and immediate.

Strategic Challenges:
Bundling of Payments for ESRD starting January 1, 2011.
Proposed rules for the new bundling initiative mandated by MIPPA were released on September 15, 2009, with a deadline for comment submission of November 16, 2009. The proposed regulations represent a vast change in how services for ESRD treatment are paid and can also profoundly change providers’ business model – i.e., management of treatment delivery will be based on optimal use of resources rather than payment for specific items and activities (fee for service). In the words of the proposed rules: the new payment methodology has among its objectives

“- - eliminating incentives to overuse profitable separately billable drugs, particularly EPO, the targeting of greater payments to ESRD facilities with more costly patients to promote both equitable payment and access to services, and the promotion of operational efficiency.”

The concept of bundling might seem to infer a simplification of the billing and reimbursement process. This is far from the fact, as outlined in the proposed regulations. Some representative examples are:

• Case mix adjustments will still apply;
• There will be monitoring of the impact of a bundled ESRD PPS approach (bundling) after implementation to ensure quality of care does not deteriorate (i.e., more reporting – perhaps using CROWNWeb as a vehicle)
• Increase in the level of payment for the first 4 months of treatment (the impact of this will differ depending on if the patient is Medicare primary or secondary at the initiation of ESRD)
• There are co-morbid conditions that increase the payment level of the bundle, such as cancers, cardiac arrest, HIV/AIDS (which can be an issue with state confidentiality laws), hepatitis B, and other conditions, which will require tracking these co-morbidities and including them on the claims. (It is still unclear if these conditions needed to be on the CMS 2728 or can be recent diagnoses).
• There is an increase in the bundled rate for “alcohol/drug dependence”, a parameter that may not be part of one’s normal data set and may require a more precise definition.
• Some co-morbid events are considered of acute nature and increase the ESRD PPS bundle for a period of 3 months at which time the bundled rate reverts to the previous value. These include pericarditis, “specified” infection, and GI bleeding. It is not clear if the increase in the bundled rate is from the date of the acute event or on a month-by-month basis.
• There are increases based on facility size with small facilities receiving an increase in bundled rate (as long as the facility is not part of an organization with near-by facilities!)
• There is a provision for “outliers” which will be paid at a higher rate. This additional payment will be accomplished by a reduction of normal ESRD PPS payment level!
• There are several options for initiating the ESRD PPS approach – adopting it for all patients at the start date (January 1, 2011) or phasing it in over 4 years. The first approach could pose a challenge of relying on the smooth functioning of the approach from the start; the second subjects the provider to what seems to be a complicated dual system where some items are included in the bundle which are not in the fee for service model. 

Reduction in payment amounts a key feature of bundling: CMS is anticipating an overall saving from introducing the payment bundle and has taken steps to realize this by reducing reimbursement relative to the fee for service model. CMS seems, with this repricing, to attempt to reduce any “windfall” that might result from provider efficiencies that result from treatment optimization. Presented as a budget neutrality adjustment overall reimbursement will be reduced 2% from the lowest payment year 2007, 2008, 2009. There are also several “adjusters” for various aspects of this approach (not elaborated on here) all of which reduce the level of reimbursement.

Unit of Payment: The decision regarding the “unit of payment” was a relief to the ESRD community, as it remains on a per treatment basis. There had been discussion to base it on an interval of time – a week of treatment (much as is done with PD) or a month. Although CMS decided on the per treatment basis, they reserved the option of changing it in the future.

Business model changes: In addition to anticipated operational changes for the dialysis provider (as stated above to “- - eliminate incentives to overuse profitable separately billable drugs, particularly EPO, the targeting of greater payments to ESRD facilities with more costly patients to promote both equitable payment and access to services, and the promotion of operational efficiency.”) there are likely to be other changes in ESRD providers’ business. Under bundling the provider is responsible for all relevant medications and this includes those now covered under Medicare Part D and currently supplied by an outside pharmacy. In addition, the provider is responsible for laboratory analyses and different contractual arrangements when specialty labs are anticipated.

Overall impact of ESRD PPS bundling: Bundling, which will go into effect 15 months from the writing of this newsletter, is expected to have a profound effect on the dialysis industry. There may be positive effects such as better management of some clinical conditions, which result in optimization of therapy. The billing and record keeping aspects of dialysis are anticipated to become considerably more complex which can place a profound burden on dialysis providers for accurate, up to date information, and the ability to easily generate claims and account for earned revenue. There are also operational issues. The timeline for implementation of bundling is tight: go-live in 15 months; CMS will be accepting comments on the proposed rules until mid-November. These comments will be reviewed before final rules are published, probably the first quarter of 2010 at the earliest; subsequent to the publication of the final rules, fiscal intermediaries (FIs) will need to interpret them and promulgate them to ESRD providers. As providers are aware, it is not until the FIs give them the specifics that they can proceed to develop the process of generating claims that will be promptly paid. QMS awaits the final details of this new claim payment system and is committed to meeting the January, 2011, deadline.

 

Strategic Challenges: CROWNWeb –
CMS insists on manual implementation.

In early 2009, CMS was persuaded to postpone its full February implementation of CROWNWeb. The effort to do so was spearheaded by several groups such as the NRAA and particularly the dialysis program at the Northwest Kidney Centers in Seattle. A pilot study (Phase I) was initiated with four providers using the CROWNWeb manual entry software provided. Three large dialysis organizations (LDOs) were permitted to batch submit their data from four facilities to the CROWNWeb database. The experience of the manual submitters was problematic. At least two of them had sophisticated clinical information systems and would have been able to send data via a batch submission. Because this was not allowed, their internal programmers designed reports to act as a “crib sheet” that mimicked the CROWNWeb entry screens. These providers forwarded comments to CMS suggesting changes regarding design and performance issues. Phase II was initiated in August and included 180 dialysis facilities, 90 of which were non-LDOs. Several QMS clients were included in this group and for QCS users we have designed “crib sheets” to assist in data entry.

In early 2009, QMS corresponded with CMS to offer our assistance in batch data submission to the CROWNWeb database which would have been straight forward from our automated systems. There have been several replies indicating ultimate interest in this method of data entry, although to date such a project has not been initiated. We continue to encourage this method of data submission emphasizing that data submission directly from sophisticated clinical databases such as QMS’s is consistent with the current national push for greater computerization in the medical field and e-connectivity. In addition, a batch submission capability would put the task of CROWNWeb submissions in the hand of a small number of IT professionals at clinics (or in our case, QMS) and eliminate the need to train clinicians for the manual entry of data that is already in a database. QMS continues to try to influence CMS to rapidly adopt this approach.

CROWNWeb, although it is now a distinct project, should not be viewed completely separate from the bundling project. Many of the performance concerns of CMS relative to bundled payment and expected changes in clinical operations will require extensive monitoring. Much of this will probably be part of the claims submission process. However, CROWNWeb will allow CMS another avenue to evaluate provider performance.

Current QMS Activities: Billing changes and increased efficiency in managing accounts receivable and assuring 100% payment of claims.

As the dialysis field has become accustomed, there have been regulatory changes that need to be addressed in a timely manner. While Medicare’s requirement for line item billing went into effect in 2008, this added detail is now required for Medicare Secondary claims. New enhancements to QMS Focus have addressed this requirement, which will go into effect October 1, 2009. There are multiple payors for ESRD services nationwide and each is governed by separate regulations and those rules can and do change. The most signification change, as discussed in a separate article in this newsletter, is a completely new national reimbursement system (Bundling). But over the recent past there have been, in addition to line item billing for Medicare Secondary Payment (MSP), several changes in state regulations that affect state Medicaid claims, which we have responded to.

QMS has committed significant effort to help our clients manage accounts receivable and assure full payment. Medicare has required that claims for ESRD patients be detailed by line item. Payment for various aspects of service are occasionally denied or are not paid at the allowable rate. Historically, this has created a frustrating task of analyzing the payment to determine the inappropriately paid item. QMS Focus has been modified to allow users to capture EOB and SVC segment information, to be able to propagate credit and adjustment information into secondary claims. While the users can still apply the full amount to the claim if it was in fact paid in full, the allocation logic in the A/R module distributes credits according the ERA file information. Finally, users will be able to capture additional claim adjustment reason codes, beyond denial codes. These changes affect all A/R functions that deal with credits.

 

Addressing strategic and immediate clinical issues – QCS:

QCS, QMS’ EMR is helping our clients address both clinical information reporting and improvement in quality of care. There are several aspects to an EMR – record keeping, data retrieval, reporting to outside agencies (CROWNWeb), and charge capture as well as helping to address issues of clinical care: mortality and morbidity in the ESRD population as well as management of specific aspects of care which will become crucial under bundling.

QCS provides powerful capabilities to provide all of these benefits - Helping clients become “paperless” – data organization, information retrieval, and charge capture. The system is completely interfaced with all dialysis machines and ESRD laboratories for a total integration of treatment and operational data. We are currently helping QMS clients who are part of the CROWNWeb Phase 2 (see above (CROWNWeb) to organize their data for the currently required manual input.

QCS organizes data to address clinical issues and these powerful information tools are a key part of this system. In a recent QMS initiative we are dedicating a full day of our users’ meeting (QMS Users’ Meeting) to discussing these clinical challenges (specifically, fluid management, vascular access, anemia management and adequacy monitoring) and how they can be better understood and addressed with data in this system.

 

Summary of challenges:

All of the issues and challenges facing the ESRD industry (bundling and CROWNWeb, as well as other pressures) translate into the need for more comprehensive, easy to use information systems, as well as increased human resources, and if not addressed will result in greater frustration on already busy clinical staff. Organization of information (using EMR's such as QCS) can reduce the impact of these demands - saving time and reducing frustration. QMS (with both QCS and QMS Focus) will continue to help the industry address the significant demands of the next few years.

 

Upcoming Events
Be sure to visit us at the upcoming trade shows!

NRAA
Booth #31
Marco Island, FL
October 7-9, 2009

The annual meeting of the National Renal Administrators Association (NRAA) will be held at Marco Island, FL from October 7th through October 10th. Come and visit the QMS booth #31 and talk to our professionals regarding how to address the upcoming challenges in the dialysis field and learn about our comprehensive approaches to managing your data – both financial and clinical.

QMS Users' Meeting 2009
October 18-20, 2009
Las Vegas, NV.
To Register go HERE or go the QMS Home page.

QMS will host its annual Users' Meeting at the Westin Casuarina Hotel and Casino &Spa October 18th through October 20th. Our industry is facing dramatic changes in the coming years-both financial as well as clinical-with new billing regulations, conditions for coverage, CROWNWeb, bundling and possibly pay for performance. These new CMS initiatives require increased emphasis on the most effective use of information and encouraging critical synergy between clinical and business professionals.

The first day's sessions will highlight the range of challenges that dialysis administrators and billers in particular are facing, as these are larger than ever before. We will concentrate on the area of reimbursement with our guest speaker's "Hot Topics" session, as well as reviewing changing regulations, and how QMS Focus is being modified to address them.

On Tuesday, October 20th, we have set aside an entire day for discussion of QCS and use of our EMR in managing patient treatment and reporting. This session will include a targeted reports workshop concentrating on at least four clinical areas: fluid management, anemia, adequacy and patient evaluation, and vascular access. To address these areas we have invited clinical experts with in-depth knowledge of these areas of treatment. We encourage you to send key clinical staff to this session, even if you are not current users of QCS. While QCS users will get a greater appreciation of the information in this program and how it can be used to address upcoming challenges, the issues that will be discussed are, and will be, critical in provision of dialysis in the coming years for all providers. We want to encourage you to send as many staff as you can to take advantage of what we consider a very important part of our meeting program.

 

QMS annual calendars for 2010:

QMS has printed annual calendars for more than a decade. These calendars have often become a key part of a facility’s planning – events, staff vacations, etc. We are in the process of sending out the 2010 version. If you have received this calendar in the past and want to assure that you will receive the 2010 calendar or if you haven’t received this useful planning tool but would like to receive one, please click here. In addition, if you would like more than one for your facility, please indicate this in the comments box.