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Federal Register / Vol. 86, No. 129 / Friday, July 9, 2021 / Proposed Rules
pediatric patients is furnished in hospitals, primarily childrens hospitals or in large dialysis organization facilities. For more information, please refer to the TEP reports.
The contractor performed analyses using the expanded age groupings suggested by the commenters and found that finer stratification of the age groups reveals differences in cost per treatment.
The contractor found that the median cost per treatment for the pediatric population using the same methodology used in the 2016 refinement but using more recent data 2018 and 2019
resulted in significant differences in cost among the pediatric age categories.
The contractor also found that the median cost per treatment for the pediatric population using the national average treatment duration, the relationship between total cost pertreatment and age is consistent with stakeholder comments.

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3. Suggestions for the Pediatric Dialysis Payment Adjustment During the December 2020 TEP, three approaches were discussed among the panelists that could potentially lead to a more accurate estimate of pediatric dialysis costs under a revised payment model: 1 The addition of pediatricspecific case-mix adjustment multipliers; 2 the creation of a separate payment bundle for pediatric ESRD
treatment costs; and 3 revisions to current data collection practices.
To illustrate how the refined model would incorporate the pediatric population, the contractor applied the model using each of the two current age groupings, resulting in an increased effect of age on costs, with multipliers of 1.61 and 1.74 for age <13 years and age 13 to 17 years, respectively, compared to the reference adult population. Please refer to the TEP
report 301 for more specific information on the analyses and discussion.
Stakeholders suggest that the variables affecting pediatric dialysis costs are sufficiently different from those associated with adult dialysis costs, and that a separate payment system may be warranted. Although the creation of a pediatric bundle or separate pediatric ESRD PPS may improve cost estimates for the pediatric population, if there were a statutory change to authorize this separate payment system, the time required for implementation would be substantial due to the subsequent need for new, 301 https www.cms.gov/files/document/endstage-renal-disease-prospective-payment-systemtechnical-expert-panel-summary-report-april2021.pdf.

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pre-implementation data collection, which providers may find burdensome.
The TEP panelists also discussed several modifications to the cost reports that they believe would better capture resources utilized in the pediatric dialysis setting. These include adding lines itemizing pediatric specific labor categories and pediatric specific supplies, clarifying cost report instructions as they pertain to pediatric dialysis, and better aligning the freestanding facility cost report with the hospital cost report. Although these changes have the advantage of being highly feasible to implement, stakeholders have noted that uptake may take additional time, as pediatric facility accounting and billing staff are not generally familiar with Medicare cost reports. Furthermore, stakeholders have noted that changes to the freestanding facility cost report would be of limited value, since pediatric dialysis primarily takes place in hospital-based facilities.
Panelists generally favored the addition of pediatric case-mix adjustment multipliers. One panelist noted that prior to the current case-mix adjustment; the multiplier applied to pediatric facilities was based on actual costs incurred during treatment that were more accurate than the costs being reported currently. The case-mix adjustment multipliers presented during the TEP were similar to the multipliers from the prior payment method, which the panelist found encouraging.
However, there was shared concern among TEP panelists that there will continue to be underpayment for pediatric dialysis patients. One panelist noted that time on dialysis may not accurately reflect all costs, and may be especially misleading for those under 2
years of age. For this patient population, expenditures on some fixed costs for example, dialysate will decrease, but staffing costs would be considerably higher, as they require one-on-one nursing and child life specialists and are more difficult to initiate on dialysis.
Therefore, panelists expressed the concern that the multipliers based on duration of treatment would not accurately reflect costs. Another panelist noted that certain state laws with personnel requirements for pediatric dialysis could also increase costs.
Panelists supported moving forward with the cost report and case-mix multiplier modifications due to the burden of implementing a new bundle.
One panelist noted that a time and motion study attempted by their dialysis organization failed, as there was a high degree of variation among facilities.

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However, another panelist described their facilitys success in securing additional funding for their pediatric dialysis unit as a result of a time and motion study.
Panelists affirmed that accounting and billing departments at childrens hospitals are not well equipped to accurately complete Medicare cost reports and suggest that this may be due both to their general lack of familiarity with Medicare one panelist noted that only 30 percent of pediatric patients are Medicare beneficiaries and the cost reports current structure.
One panelist cautioned that because most pediatric dialysis is delivered in the hospital setting, if the revised hospital cost report does not include the modifications recommended for the dialysis facilitys cost report, pediatric expertise for dieticians, social workers, child life specialists, and behavioral specialists may remain overlooked.
Despite this, panelists expressed the desire to move forward with the suggested cost report modifications to improve pediatric payment, which is presented later on in the preamble in section VI.H of this proposed rule.
4. Request for Information for Pediatric Dialysis Payment CMS is soliciting feedback from the public on pediatric dialysis payment. In addition to any other input the public wants to provide for the pediatric dialysis payment adjustment, we are requesting responses to the following questions.
Does the magnitude of total costs and pediatric multipliers reflect ESRD
facilities actual incurred costs? If not, what specific costs are not being reported on claims and/or cost reports?
Is there sufficient variation in composite rate costs among pediatric patients to justify use of a proxy to distribute facility-level composite rate costs to individual treatments?
If duration of treatment is not a valid proxy for composite rate costs per treatment, what are alternative proxies to consider?
What, if any, are the specific concerns about incorporating pediatric patients into the estimation of multipliers for both the adult and pediatric populations?
What are the issues facing pediatric billing and accounting staff with regard to completion of claims and cost reports? How can these problems be remedied?
Are there additional costs factors for pediatric patients that are not adequately captured on the 72X claim?

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