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Federal Register / Vol. 86, No. 129 / Friday, July 9, 2021 / Proposed Rules application of the basic case-mix adjustments, using regression-based adjustment factors for the patient variables of age, BSA and BMI are explained in each of those rules 69 FR
47529 through 47531 and 69 FR 66323
through 66324, respectively. The product of the specific adjusters for each patient, multiplied by the otherwise applicable composite payment rate, yielded the basic case-mix adjustment as required by statute. The basic casemix adjusted composite payment system was effective April 1, 2005 and continued until the ESRD PPS was implemented on January 1, 2011.
As we explained in the CY 2005 ESRD
PPS final rule with comment period 69
FR 66326 through 66327, we attempted to develop case-mix adjusters for outpatient patients with ESRD under age 18. However, we found that for the approximately 600 Medicare pediatric patients for whom claims were available from 2000 through 2002, the results were highly variable and statistically unstable, and therefore, inappropriate for the development of case-mix adjusters in accordance with the same methodology otherwise applicable to adult Medicare patients with ESRD.
For this reason, we described an alternative methodology we used to develop a 62 percent pediatric increase that is, an adjustment factor of 1.62
applied to the composite payment rate per treatment for any facility furnishing outpatient dialysis services to pediatric patients. That factor was based on the average amount of the atypical services exceptions granted for 20 ESRD
facilities, each of which sought and received an exception for the atypical costs incurred for the treatment of outpatient pediatric patients, compared to the average unadjusted composite payment rate that is, the payment without regard to exception amounts for these same 20 facilities. We explained that application of the pediatric adjustment factor of 1.62 in lieu of an explicit pediatric case-mix adjustment was temporary, and would be eliminated once an appropriate methodology, preferably one applicable to both pediatric and adult Medicare patients, could be developed.
In the CY 2011 ESRD PPS proposed rule 74 FR 49986 through 49987, we proposed a pediatric payment methodology with comorbidity adjusters. However, in the CY 2011
ESRD PPS final rule 75 FR 49130
through 49134, in response to public comments, we explained that instead of using the regression-based composite rate multiplier of 1.199, we established the pediatric payment adjusters using the overall difference in average
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payments per treatment between pediatric and adult dialysis patients for composite rate services in CY 2007
based on the 872 pediatric dialysis patients reflected in the data. That is, the average CY 2007 MAP for composite rate services for pediatric dialysis patients was $216.46, compared to $156.12 for adult patients. We used CY
2007 data consistent with our determination that 2007 represented the year with the lowest per patient utilization of dialysis services in accordance with section 1881b14Aii of the Act. We developed payment adjusters using the variables of age that is, <13 and 1317
and modality peritoneal dialysis or hemodialysis.
In the CY 2016 ESRD PPS final rule 80 FR 68968, we refined the ESRD PPS
in accordance with section 632c of ATRA, which required CMS to conduct an analysis and make appropriate revisions to the case mix payment adjustments. We analyzed the case-mix payment adjustments under the ESRD
PPS and revised the payment adjusters using CYs 2012 and 2013 ESRD claims and cost report data. For pediatric dialysis, we used the same methodology that was used for the CY 2011 ESRD
PPS final rule, except for the use of more recent data years 2012 through 2013 and in the method of obtaining payment data. Specifically, we used the projected MAP based on 2013 claims to calculate the ratio of pediatric total MAP per session to adult total MAP per session. The resulting adjustment factors reflected an 8.21 percent increase to account for the overall difference in average payments per treatment for pediatric patients. The pediatric adjusters that were finalized for CY 2016 and are currently in effect are: <13 peritoneal dialysis = 1.063 <13 hemodialysis = 1.306
1317 peritoneal dialysis = 1.102
1317 hemodialysis = 1.327
2. Current Issues and Stakeholder Concerns Since 2015, we have continued to hear from organizations associated with pediatric dialysis about the undervaluation of pediatric ESRD care, which requires significantly different staffing and supply needs from those required to deliver ESRD care to adults.
These organizations support CMS efforts to explore ways to improve collecting pediatric-specific data to better characterize the necessary resources and associated costs of delivering pediatric ESRD care. Commenters have also suggested that we reinstate the exceptions process that would provide
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individual hospitals and ESRD facilities with their own payment rate based on their costs. We note that this approach would require a statutory change because section 1881b14Ai of the Act requires the Secretary to implement a payment system under which a single payment is made to all ESRD facilities.
Stakeholders have informed us that costs unique to pediatric dialysis are not adequately captured in current cost reports or claims, and therefore are not accounted for in the pediatric adjustments. In addition, they have explained that pediatric dialysis often requires developmental and behavioral specialists, pediatric dieticians, and social workers, and that pediatric comorbidities require unique specialized care. Further, pediatric nephrologists have told CMS that pediatric patients disproportionately receive treatment in hospital-based facilities, but the hospital cost report CMS Form 255210 does not distinguish pediatric and adult dialysis cost.
One organization suggested that we expand the pediatric age groups and create either pediatric modifiers or a pediatric add-on payment by age group.
Alternatively, the organization suggested that we create a pediatricspecific ESRD bundle that would allow for full accounting of costs for pediatric staffing and specialized equipment, and the economic implications of pediatric medical comorbidities that are not addressed in the current PPS. In order to engage dialysis stakeholders in advance of rulemaking, CMS data contractor conducted TEP discussions for the past three years on various dialysis payment approaches and issues.
For the 2020 TEP, one of the discussion topics was pediatric dialysis. Based on discussions and meetings with stakeholders and TEP panelists, the contractor performed several analyses on pediatric dialysis to inform the TEP
discussion. The analyses confirmed many of the challenges reflected in stakeholder comments regarding pediatric dialysis.
For example, a small number of facilities provide 95 percent of pediatric dialysis treatments approximately 100
and those pediatric facilities are hospitals, mostly childrens hospitals.
Pediatric treatments are split between home peritoneal dialysis mostly for children younger than 13 and in-center hemodialysis for older children 1317.
One analysis, using cost report data, found that the median registered nurse/
licensed practical nurse hours pertreatment is higher in pediatric facilities and pediatric comorbidities require more specialized staffing. Dialysis for
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