Statement of the Renal Physicians Association

The Renal Physicians Association (RPA) is the professional organization of nephrologists whose goals are to ensure optimal care under the highest standards of medical practice for patients with renal disease and related disorders. RPA acts as the national representative for physicians engaged in the study and management of patients with renal disease. RPA greatly appreciates the interest of Ways and Means Health Subcommittee Chair Pete Stark and Ranking Minority Member Dave Camp in exploring new methodological options for enhancing the quality and efficiency of care delivered by Medicare physicians. Further, we appreciate the Subcommittee’s efforts to exercise its oversight authority as the Centers for Medicare and Medicaid Services carries out its fiduciary responsibility to maximize the effectiveness of Medicare program spending.

RPA believes it has a unique perspective to offer on the issues being considered by the Subcommittee, as nephrologists have been reimbursed through the use of a monthly capitated payment (MCP) system for the bundle of physicians’ services associated with the care provided to patients with end stage renal disease (ESRD) for over thirty years. Further, nephrologists have been involved in the gathering and reporting of clinical performance measure (CPM) data since 1994 through the CMS Core Indicators Project. As a result, provision of care to chronically ill patients under bundling and quality measurement structures that are just now being proposed broadly across all specialties has been a way of life for nephrologists for many years, and thus RPA believes our insights would be of use to the Subcommittee.

In this collaborative spirit, we offer the following recommendations for consideration in the development of new methodologies to improve the quality and efficiency of the care provided by Medicare physicians. These recommendations are organized into two sections, the first addressing quality related issues and the second relating to the reimbursement structure issues involved in the development of bundled payment systems and similar models.

Quality Issues

RPA believes that in order to develop an effective and workable payment methodology linking reimbursement to quality, Congress, CMS, MedPAC and other policymakers must actively involve and draw on the intellectual resources and experience of the physician community throughout the process. This will help to ensure that the development and final products emphasize the expected benefits of a modified payment methodology and minimize negative unintended consequences.
RPA supports the development of performance-based payment system that considers and separately rewards both high quality patient care and measurable improved performance.

RPA believes that for such a revised payment methodology to be effective longitudinally, the system must not disrupt the resource-based relative value scale (RBRVS) system, and must for the purposes of the incentive payments have budget neutrality waived. Incentive payments should not be derived by decreasing usual payments or establishing a withhold from the usual payments.

RPA believes that to effectively implement a payment methodology linking reimbursement to quality, Congress must consider fundamental change to the policy structure underlying the Medicare program, specifically assessing the desegregation of the Medicare Part A and Part B funding pools. RPA believes that the artificial separation of inpatient and outpatient reimbursement does not allow for enhanced Medicare program cost efficiency through the investment of Part A savings in outpatient care services.. Physician activities that improve quality and produce savings by decreasing hospitalizations ought to be accounted for in the adjudication of the funds available for physician incentive reimbursement.
RPA believes that Congress must support substantial research in both the pertinent basic science and health services arenas, especially related to outcomes research, in order to strengthen the essential and necessary scientific evidence supporting a transition to a performance-based payment system.

Reimbursement Structure Issues

RPA supports the use of bundled payment systems to provide medically appropriate care to specific patient sub-populations, and to promote efficient use of Medicare program resources. RPA believes that the reimbursement for bundled payment systems must not only cover the services included in the bundle but also be sufficient to promote the use of electronic medical records, integration of emerging technologies, and other innovations in medical practice. Further, RPA believes that a mechanism for periodic review of the bundle must be included when the bundle is developed, with review of the reimbursement for the bundle being required if and when services are added to or removed from the bundle.
RPA believes that physician reimbursement system revisions should include assurance of reasonable payment that encourages the medically appropriate site of care to be utilized, including payment at all sites of care where services are provided. Such a policy revision would address situations where the patient is admitted to the hospital for services that are medically appropriate to be provided in the outpatient setting but are often provided in the inpatient setting due to the absence of a payment mechanism in the outpatient setting. For example, in renal care, patients with acute kidney failure who are expected to regain their renal function often cannot be dialyzed in the outpatient setting because of the difficulty that dialysis facilities and outpatient hospital departments experience in being reimbursed for the facility services related to dialysis. Review and revision of such seemingly arbitrary reimbursement guidelines would facilitate more efficient use of Medicare program resources.
RPA believes that expanded coverage for medically appropriate utilization of services to maintain and improve quality of care should be provided. While the expansion of covered preventive services in the Medicare program in areas such as diabetes treatment represents a significant step forward, the potential for achieving greater cost-efficiency in this area is profound. For example, in kidney care there are a variety of interventions and treatment modalities specific to the ESRD patient population that would enhance the quality of care provided but for which there currently is either no Medicare reimbursement or such reimbursement is extremely difficult to obtain. Examples of these services include certain procedures related to monitoring and maintaining the patient’s vascular access, use of essential oral medications including phosphate binders and multivitamins, and provision of nutritional supplements. Coverage of these services over time will likely lead to decreased per-patient costs over time.

RPA believes that reimbursement for effort and practice costs associated with required quality improvement and patient safety services should be accounted for as payment system revisions are developed. Recognizing that programs such as the Physicians Quality Reporting Initiative (PQRI) and other CMS managed demonstration projects are currently only voluntary, before these programs are made mandatory, there should be corresponding consideration of the expenses to the physician’s practice of providing these services. In renal care, while it is appropriate that nephrologists should be expected to lead continuous quality improvement (CQI) processes in dialysis facilities and their own practices, assuming responsibility for the full cost of these services should not be part of that expectation.

Conclusion

RPA supports Congress’ efforts to seek improvement in the quality and efficiency of the care provided by Medicare physicians to program beneficiaries. We urge Congress to approach these issues thoughtfully and deliberately in order to minimize the impact of any unforeseen negative consequences. In the area of quality improvement, we urge Congress to (1) continue its efforts to include physicians in the development of such a system; (2) direct CMS to develop a performance-based system that rewards both high performance and measurable improved performance; (3) ensure that such a system does not disrupt the RBRVS system and identifies separate funding for incentive payments; (4) assess desegregation of the Medicare Part A and Part B funding pools; and (5) support the basic research and health services research necessary to make such change evidence-based. With regard to reimbursement structures, Congress should (1) require periodic review of any bundled payment, and the bundle of services itself; (2) provide reasonable payment that encourages the medically appropriate site of care to be utilized; (3) expand coverage for medically appropriate preventive services, especially in the treatment of chronic diseases; and (4) account for the effort and practice costs associated with enhanced quality improvement and patient safety services. Once again, RPA appreciates the opportunity to provide our perspective on these issues to the Committee, and we make ourselves available as a resource to the Committee in its future efforts to ensure the best possible health outcomes and quality of life for all Medicare beneficiaries, and especially those with kidney disease.