Comments to CMS re: Renal Prospective Payment System

September 2, 2014
Marilyn Tavenner, MHA RN
Administrator, Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1614-P
P.O. Box 8010
Baltimore, MD 21244-8010

Re: Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies; Proposed Rule (CMS-1614-P)

Dear Ms. Tavenner:

The Academy of Nutrition and Dietetics (the “Academy”) appreciates the opportunity to submit comments to the Centers for Medicare and Medicaid Services (CMS) at the United States Department of Health and Human Services (HHS) related to its July 11, 2014 proposed rule, “Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies.” Representing more than 90,000 registered dietitian nutritionists (RDNs),1 dietetic technicians, registered (DTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States and is committed to improving the nation’s health through food and nutrition across the lifecycle. RDNs provide medical nutrition therapy in dialysis facilities, clinics, hospitals, university settings, and private practice. Through their direction and leadership, RDNs strive to advance the nephrology nutrition clinical practice, education, and research while promoting continuing education programs for dietitians and other healthcare professionals.
The Academy generally supports CMS’s continued implementation and improvement of the case-mix adjusted bundled prospective payment system (PPS) for Medicare outpatient End-Stage Renal Disease (ESRD). The Academy continues to support quality improvement programs (QIP) as an effective method of assessing facility performance measures and of assuring and incentivizing quality ESRD services that foster improved patient outcomes. The Academy offers these comments to CMS regarding certain factors and reported performance measures, including:

  • ESRD PPS base rate and high cost outliers;
  • Update to the labor-related share; and
  • Quality measures for mineral metabolism and hypercalcemia.

ESRD PPS Base Rate and High Cost Outliers
The Academy supports CMS’s rebasing of the End Stage Renal Disease bundled (ESRDB) market basket to reflect updated, accurate data for the ESRD PPS that accounts for population shifts and labor market conditions. We also encourage urge CMS to ensure ongoing stagnation in the payment rate does not negatively impact patient care. Specifically, the Academy is concerned about decreases in payments to rural facilities and appreciates CMS’s consideration of the potentially disproportionate impact on them. Low-volume payment adjustments designed to ensure beneficiaries’ access to otherwise unavailable dialysis options could be limited to facilities located farther than a specified distance from its nearest facility.

The Academy also supports section 1881(b)(14)(D)(ii) of the Social Security Act allowing for a payment adjustment and the proposed recalibration of the fixed dollar loss amounts for high cost outliers due to unusual variations in the type or amount of medically necessary care, including variability in the amount of ESAs necessary for anemia management.

Update to the Labor-Related Share
CMS proposes to revise the ESRDB market basket to reflect changes in cost weights such that the proposed labor-related share increases significantly to 50.673% from the current labor-related share of 41.737%, while proposing a two-year transition to minimize impact on facilities with low wage index values. Given the enhanced role of RDNs and other providers in improving outcomes and promoting therapy adherence, including dialysis treatments, dietary recommendations, and medication regimes, the Academy supports the proposed ESRDB market basket revision recognizing the value of labor-related care and the temporary adjustment that will reduce the disparity of impacts on rural and urban facilities.

Quality Measures for Mineral Metabolism and Hypercalcemia
The Academy remains concerned about the proliferation of quality measures generally and appreciates CMS’s willingness to review measures used in the ESRD QIP for reasonableness. We support the change, beginning in the PY 2018 program year, in the reporting measure for mineral metabolism to allow facilities to submit both serum phosphorous and plasma phosphorous as comparable and similar measurements. In addition, the Academy supports CMS’s recognition that there are not available outcome-based measures for hypercalcemia at this time.

The Academy commends CMS for having removed serum calcium levels as part of the mineral metabolism measures since serum calcium levels will be monitored to ascertain whether they meet the calcium goal of 10.2 mg/dl as defined by V546 in the Measures Assessment Tool and thus inclusion of the reporting measure would be redundant. The Academy also believes it is critical that CMS show additional non-observational data regarding management of serum calcium in ESRD patients prior to any determination to include this measure as a quality metric in the final rule.

The Academy sincerely appreciates the ongoing opportunity to offer comments regarding this important ongoing initiative, specifically related to proposed changes to the ESRD QIP. Please contact either Jeanne Blankenship by telephone at 202/775-8277 ext. 1730 or by email at or Pepin Tuma by telephone at 202/775-8277 ext. 6001 or by email at with any questions or requests for additional information.

Jeanne Blankenship, MS RDN
Vice President, Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics

Pepin Andrew Tuma, Esq.
Director, Regulatory Affairs
Academy of Nutrition and Dietetics

1 The Academy recently approved the optional use of the credential “registered dietitian nutritionist (RDN)” by “registered dietitians (RDs)” to more accurately convey who they are and what they do as the nation’s food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.