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Medicare Program: Proposed Revisions to Payment Policies Under the Physician Fee Schedule

Creation/Revision Date: December 23, 2008

December 23, 2008

Mr. Kerry Weems 
Centers for Medicare & Medicaid Services 
Department of Health and Human Services 
Hubert H. Humphrey Building 
Room 445-G 
200 Independence Avenue, SW 
Washington, DC 20201 

Subject:     Medicare Program: Proposed Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for 
CY 2009; (CMS-1403-FC) Final Rule

Dear Mr. Weems:

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 selected portions of the 2009 Medicare Fee Schedule Final Rule.

RPA’s comments will focus on the following issues: 

  • Physicians Quality Reporting Initiative (PQRI) 
  • E-Prescribing Incentive Program 
  • The Impact of the Final Rule on Interventional Nephrology Services

Physicians Quality Reporting Initiative (PQRI) 
In the final rule, there are two circumstances that RPA believes will unnecessarily limit nephrologist participation in the 2009 PQRI program, and we urge the Agency to address these issues. First, CMS indicates in the final rule that it is limiting 18 PQRI codes to only registry-based reporting due to their “complex specifications”. Of those 18 codes, 3 are end-stage renal disease (ESRD) measures (hemodialysis plan of care, peritoneal dialysis plan of care and pediatric dialysis adequacy), the result of which is that only nephrologists who use registries will be able to report those 3 codes (in addition to the fact that the vast majority of nephrologists will never have reason to report a pediatric measure).

RPA is concerned that since the anemia plan of care measure and the vascular access measure were removed from PQRI for 2009 because the National Quality Forum (NQF) declined to endorse them, only one ESRD PQRI measure (flu vaccination) that can be reported via the claims process remains. Therefore, those nephrology practices that only provide ESRD care will have little opportunity to participate in PQRI for 2009 unless they use the registry measures.

It is RPA’s opinion that the justifications offered in the rule for requiring those three measures to be reported via registry are not valid. As the agency knows, none of these measures in their current iteration were included in the 2007 PQRI program. In 2007, CMS created 2 ESRD-specific measures, hemodialysis adequacy and anemia plan of care. In 2008, CMS adopted five ESRD measures that were developed by the AMA Physicians Consortium for Performance Improvement (PCPI) that included the hemodialysis plan of care and peritoneal dialysis plan of care measures for the PQRI program. [The pediatric dialysis adequacy measure is new for 2009.] The rule states that the 18 registry-only measures either require too many diagnoses codes (not applicable to ESRD measures), or that there were a low number of satisfactory submissions during the 2007 PQRI and/or there was a high occurrence of inaccurate quality data codes reported in 2007. Both of these points may in fact be true, but RPA believes that given that 2007 was the first year of PQRI during which the program experienced many growing pains, it seems unfair to base 2009 requirements on issues that may not be the fault of the reporting physician and may be due to systematic shortcomings of the PQRI program itself. RPA recommends that the three ESRD measures to be included on the ‘registry-only’ list be removed from that list and be reportable via the claims based system.

Further, CMS eliminated chronic kidney disease (CKD) measure #120 (ACE/ARB therapy), noting that “our analysis of 2007 PQRI results indicate that there were no satisfactory submissions and no quality data codes accepted for these measures during the 2007 PQRI.” Since CKD measures did not exist until the 2008 PQRI program, there would be no satisfactory submissions or quality data received for 2007. RPA therefore strongly recommends that CMS restore CKD measure #120 to the 2009 PQRI because it was removed seemingly by error.

RPA is sensitive to the challenges presented by the implementation of a program the scope and size of PQRI, and we of course support the overarching goal of such programs to improve the quality of care provided to Medicare beneficiaries. However, we do believe that the two situations described above will create barriers to nephrologist participation in PQRI in future years, and thus urge that our recommendations be accepted.

Electronic Prescribing Eligibility 
RPA supports the adoption and use of health information technology such as electronic prescribing to improve patient safety and quality of healthcare, and believes that the potential for additional payments by Medicare for the use of e-prescribing is an effective incentive for more widespread adoption. However, RPA is concerned that the current eligibility requirement may preclude the participation by the majority of practicing nephrologists.

Our concern centers on the requirement that eligible professionals whose estimated allowed Medicare Part B charges for the e-prescribing measure codes, as defined by the e-prescribing denominator, must be at least 10% of their total Medicare Part B allowed charges. It is our belief that this will limit the ability of nephrology practitioners to participate in the incentive program due to the small percentage of their billed charges reflected by the e-prescribing measure codes. The proposed rule states that CMS is limiting the scope of the denominator codes to professional services that occur in the professional office and outpatient settings for 2009. Nephrology practitioners routinely provide the type of outpatient services to Medicare beneficiaries intended to be captured by this program; however these unique set of services are reported monthly through CPT codes not included in the e-prescribing measure denominator.

As the e-prescribing incentive program is refined in future years, RPA urges CMS to consider addressing this eligibility requirement to ensure that the intent of the program, to urge adoption and use of electronic prescribing capabilities, is appropriately applied to all Medicare providers who routinely provide office and outpatient services to Medicare beneficiaries.

Impact of Final Rule on Interventional Nephrology Services
One of the most significant refinements for the 2009 Medicare Fee Schedule was the legislatively mandated change to achieve budget neutrality through the conversion factor rather than the work values, as had been the case since 2007. RPA recognizes that in a budget-neutral world, implementation of such a change will benefit some categories of services and disadvantage others, and we acknowledge that RPA and other groups within the organized medicine umbrella advocated for this methodological revision.

Having noted that, RPA feels compelled to put a spotlight on the impact of the implementation of the revised methodology on services typically provided by interventional nephrologists, and the resulting implications for the CMS-supported Fistula First Breakthrough Initiative (FFBI) program. [The mission of the FFBI is to promote the use of arteriovenous fistulas (AVFs), which, according to FFBI, “last longer, need less rework or repairs, and are associated with lower rates of infection, hospitalization, and death.”] It is our understanding that for the common portfolio of interventional nephrology services, particularly those provided in the physician’s office setting, reimbursement is likely to be reduced by 10-15%. RPA is concerned that such a substantial reduction in the reimbursement for these services in the physician’s office setting will make it prohibitively expensive to provide this care, reducing patient access to these critically important services in a way that would run counter to the broad goals of FFBI. This could cause these services to be provided in settings where the cost to the Medicare program would be substantially higher. For these reasons, we urge CMS to more carefully review the impact of the reimbursement reduction for these services to ensure that high-priority initiatives supported by the Agency such as the FFBI program are not adversely affected.

As always, we welcome the opportunity to work collaboratively with CMS in its efforts to improve the quality of care provided to the nation’s ESRD 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 Director of Public Policy

Alan S. Kliger, M.D. 

Renal Physicians Association

1700 Rockville Pike
Suite 220
Rockville, MD 20852

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

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