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RPA Response to Senate Finance Committee Chronic Care Working Group Policy Options Document

Creation/Revision Date: January 26, 2016

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January 26, 2016 

The Honorable Johnny Isakson 
The Honorable Mark R. Warner 
Co-Chairs, Senate Finance Committee Chronic Care Working Group 
United States Senate 
Washington, DC 20510-6200 

Subject: Request for Input on SFC CCWG Policy Options Document 

Dear Senators Isakson and Warner: 

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 kidney disease and related disorders. As the national representative for physicians with expertise in the practice of nephrology, RPA is poised to offer comments on the impact of regulatory and policy issues on the provision of both optimal and individualized care from the perspective of the practicing physician. 

We are writing to offer comments on selected issues raised in the Policy Options Document issued by the Finance Committee’s Bipartisan Chronic Care Working Group (CCWG). Our comments will address expanded access to home dialysis modalities, allowing Medicare beneficiaries with end-stage renal disease to choose Medicare Advantage plans, and efforts to improve and encourage the use of chronic care management services in the Medicare program. 

Expanding Access to Home Hemodialysis Therapy

In the policy options document, the CCWG notes that it is considering expansion of Medicare’s qualified originating site definition to include free-standing renal dialysis facilities located in any geographic area. As noted in our comments to the CCWG in June, exclusion of the dialysis facility from the list of originating sites in effect eliminates a majority of the locations from which kidney disease-related telehealth services may originate, and thus RPA would support this proposal. Later in the document the CCWG raises the issue of adding the patient’s home to the list of originating site list as well. While we recognize that there are Medicare regulatory compliance issues that would make designating the home as an approved originating site a more complex proposition, we believe that to the extent that these issues can be resolved, that would be appropriate as well. 

Within this section of the options document the Working Group also inquires about whether any safeguards should be in place for beneficiaries who are undergoing home dialysis therapy and would be utilizing their expanded access to monthly visits via telehealth, such as a requirement that there be at least one in-person visit every three to six months. RPA emphatically believes that such safeguards should be in place, and that there must be at least one face-to-face visit between the home dialysis patient and the nephrologist in a three consecutive month period. Further, RPA strongly believes that the optimal frequency of patient/physician interactions for all home ESRD MCP patients is a monthly face-to-face visit interaction with his/her nephrologist. It is worth noting that the disease burden for the typical home dialysis patient includes Type II diabetes mellitus, vascular disease, hypertension, secondary hyperparathyroidism, anemia, and polypharmacy (i.e., use of greater than seven medications). Therefore, even stable, relatively healthy home dialysis patients still have a multiplicity of chronic diseases beyond that of all but a small percentage of other Medicare beneficiaries. Accordingly, while RPA supports the increased use of telehealth services in the ESRD population where appropriate, we do believe that there must be a minimum of one face-to-face visit between the home dialysis patient and the nephrologist in a three consecutive month period, and that use of telehealth in this population should be more of an exception rather than a rule. 

Allowing ESRD Beneficiaries to Choose a Medicare Advantage Plan 

In the options document, the CCWG proposes allowing ESRD beneficiaries to enroll in a Medicare Advantage (MA) plan regardless of the onset of their condition;RPA supports this proposal. It should be acknowledged that not all ESRD beneficiaries will benefit from or choose to be insured by a Medicare Advantage plan, as some of those plans may for example have patient cost-sharing requirements or limited access to the patient’s specialist of choice that would render a specific plan undesirable. However, the desirable aspects of many such plans, such as expanded access to pharmaceutical drugs and nutritional supplements, transportation assistance, and possible out-of-pocket cost limits may more than offset their shortcomings. Either way, RPA believes that this is an issue of patient choice, and thus the option to elect MA plans should be available to Medicare ESRD beneficiaries. 

Improving/Encouraging Use of Chronic Care Management Services

Under the subtitle of Improving Care Management Services for Individuals with Multiple Chronic Conditions, the Working Group includes a proposal to establish a new high-severity chronic care management code that would capture non face-to-face activities provided to highly complex patients with multiple chronic conditions. RPA fully supports this proposal, as it would be a relatively straightforward means of accounting for the diverse scope of services provided to patients with high complexity across a multitude of care settings within the existing evaluation and management coding structure. 

Related questions posed by the CCWG pertain to patient criteria for the high severity CCM code, eligible providers, and whether the code should be permanent or temporary. Regarding patient criteria, the thought process resulting in the possible alternatives specially outlined in the options document (patients with five or more chronic conditions, one chronic condition in conjunction with Alzheimer’s or a related dementia, or a chronic condition combined with impaired functional status) is reasonable, although RPA believes that four rather than five chronic conditions may be a more appropriate threshold. 

On the issue of eligible providers, there is no reason to treat this code differently than the existing chronic care management code, in which the CPT code descriptors describe the services as “furnished by physicians or other qualified health professionals, which for Medicare purposes is consistent with allowing these codes to be billed by the physicians and NPPs (non-physician practitioners) whose scope of practice and Medicare benefit category include the services described by the CPT codes and who are authorized to independently bill Medicare for those services” as noted in the Medicare Fee Schedule final rule for 2016 that concluded initial policy development for this code. RPA thus believes that physicians and other qualified health professionals as described above should be eligible providers for these services. 

With regard to whether the code is permanent or temporary, we believe that the service should be designated as having an active status (‘A’ in the fee schedule), as opposed to having inactive status (‘I’ in the fee schedule) and be a full-fledged CPT code, rather than being established as a G-code (which is temporary and inconsistently covered and reimbursed by Medicare regional contractors). For the Working Groups’ objective in creating the code to be achieved, the service has to be given a reasonable and legitimate chance at implementation; inconsistent application will not suffice. Additionally, there is precedent at CMS for swift development and implementation of a newly created service, as the transitional care management codes (CPT codes 99495 and 99496, which are related but not directly akin to the chronic care management services) proceeded from development to implementation in approximately 18 months’ time. As such, RPA urges the CCWG to designate that the new high severity chronic care management code should be designated as an ‘A’ status code in the Medicare Fee Schedule. 

Also under the rubric of encouraging use of chronic care management services, the CCWG inquires about the benefit of waiving the beneficiary co-payment associated with the current chronic care management code as well as the proposed high severity chronic care code. RPA learned from numerous nephrology practices across the country that when the kidney disease education (KDE) benefit was implemented in 2010, the necessity of the co-payment (which physician practices are required by law to attempt to collect) served as a substantial barrier for those practices seeking to provide the benefit. RPA would posit that the long term benefit of providing proactive chronic care management to the most complex patient sub-populations in the Medicare universe far outweighs the value of collecting the patient co-payments for these services. RPA therefore urges the CCWG to recommend that patient co-payments for high severity chronic care management services be waived. 

As always, RPA welcomes the opportunity to work collaboratively with the Senate Finance Committee and the Chronic Care Working Group specifically in its efforts to improve the quality of care provided to the nation’s kidney patients, and we stand ready as a resource to the Subcommittee in its future endeavors. Any questions or comments regarding this correspondence should be directed to RPA’s Director of Public Policy, Rob Blaser, at 301-468-3515, or by email at rblaser@renalmd.org

Sincerely, 
Rebecca Schmidt DO signature
Rebecca Schmidt, DO 
President 

Renal Physicians Association

1700 Rockville Pike
Suite 220
Rockville, MD 20852

Phone: 301-468-3515
Fax: 301-468-3511
Email: rpa@renalmd.org

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