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RPA Comments on ESRD Networks Scope of Work (SOW)

Creation/Revision Date: February 23, 2012

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Renee Dupee, Senior Advisor, Quality Improvement Group 
Office of Clinical Standards and Quality 
Centers for Medicare and Medicaid Services 
Department of Health and Human Services 
Attention: CMS-1524-P 
Mail Stop S3-02-01 
7500 Security Boulevard 
Baltimore, MD 21244-1850 

Subject: ESRD SOW Comments 

Dear Ms. Dupee: 

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. We are writing to provide comments on the proposed ESRD Network Scope of Work (SOW). 

RPA’s comments will focus on the following issues: 

 Resource Intensiveness of SOW Proposals
 Impact of Pre-Dialysis Care on Network Performance
Resource Intensiveness of SOW Proposals

Overall RPA is supportive of the concepts set forth in the SOW document, as it seeks to follow the CMS “Triple Aim” goals of promoting better care for individuals, better population health, and reduced per capita costs in the Medicare program, and also has a focus on patient centered improvements in care. However, we are concerned that the Networks have been assigned significant additional responsibilities without commensurate resource or funding increases. 

Examples of the types of additional activities for which the Networks will be held responsible as of the implementation of the SOW include but are not limited to: 
Unit level oversight and sanctioning
Required participation in “voluntary surveillance” with the National Healthcare Safety Network (NHSN), with the Networks held being responsible for achieving an 80% enrollment rate by June 20, 2013)
Responsibility for oversight of the ESRD Quality Improvement Program (QIP) including resource and technical help at the facility level
Responsibility for monitoring CROWNWeb and input of the data
While RPA fully supports the performance and management of all of the activities listed above, we also believe that adding these to the ESRD Networks’ current scope of work in the absence of additional funding or resource allocations is unrealistic and destined to result in a less than optimal outcome. We therefore urge the Agency to either allocate additional funding to achieve these objectives, or scale back the additional responsibilities assigned to the Networks. 

Impact of Pre-Dialysis Care on Network Performance

RPA believes that one issue of great importance that is not addressed in the SOW is the impact of pre-ESRD care on outcomes after initiation of chronic dialysis. The SOW is limited to care after the initiation of dialysis, without recognizing that the care provided prior to initiation of dialysis has a major impact on outcomes during dialysis. This is particularly true in the first months of dialysis, when mortality is highest. Thus, it is unreasonable for CMS to hold the Networks accountable for decreasing the percentage of patients with catheters and increasing the utilization of arteriovenous fistulas at initiation of dialysis, when they do not have an oversight role in the pre-ESRD arena. 

As always, RPA welcomes the opportunity to work collaboratively with CMS in its efforts to improve the quality of care provided to the nation’s kidney patients, and we stand ready as a resource to CMS 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

Thank you, 

Ruben Velez signature

Ruben L. Velez, MD 

Renal Physicians Association

1700 Rockville Pike
Suite 220
Rockville, MD 20852

Phone: 301-468-3515
Fax: 301-468-3511

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