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Federal Register / Vol. 86, No. 129 / Friday, July 9, 2021 / Proposed Rules
The facility-level cost components of interest include capital costs related to dialysis machines and other equipment used in dialysis treatment, labor costs, and supply costs. Based on the input received and further analysis conducted by the data contractor, several specific changes to the cost reports were suggested. These include changes in the reporting of composite rate components:
1 Capital costs for dialysis machines and related equipment, 2 direct patient labor costs, 3 administrative and managerial costs, and 4 differentiation of separately billable from composite rate laboratory and supply costs. The suggested changes would also require reporting of these costs by modality.
While the step down worksheet Worksheet B1 in the current cost report separates capital and labor costs by modality, this separation is based on proportionally allocating costs according to a specified statistical basis for example, treatment counts, rather than the reporting of actual capital and labor resources associated with each modality. The data contractor and panelists agreed that changing the specifications in the instructions to the cost report to indicate that the allocations be made on the basis of actual resource use, would allow for a better estimation of component costs per treatment and analysis of how these costs vary among patient groups and across modalities.

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b. Costs for Capital-Related Assets That Are Dialysis Machines Based on stakeholder feedback, CMS
would like to understand difficulties ESRD facilities have in reporting capital costs, particularly as they relate to dialysis machines. Both TEP panelists and dialysis associations have suggested that modifications to reporting of the capital costs of dialysis machines focus on two goals. The first goal is to improve the fidelity and comparability of dialysis machine capital cost reporting across individual facilities.
They suggested that this would be achieved with more specific instructions for completing the cost report. The second goal is to ensure CMSs ability to distinguish between dialysis machine capital costs among various modalities and dialysis settings in a way that preserves fidelity and comparability among facilities. This could be achieved with revisions to the cost report itself. As suggested by panelists and some stakeholders, to achieve these ends, revisions to the cost report related to dialysis machine capital costs might include:

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Improve the instructions related to the reporting of dialysis machine capital costs.
++ For purchased equipment: Specify purchase price, depreciation, maintenance, repair, insurance, replacement.
++ For rented equipment: Specify rental rates, maintenance, repair, insurance, rent escalators.
List and stratify the costs of capital equipment used in dialysis treatment by setting and modality.
++ Differentiate between rented and purchased equipment.
++ Differentiate among machines used in-facility and in the home setting.
++ Differentiate machine costs in the home setting by modality for home hemodialysis and home peritoneal dialysis.
++ Include water treatment machines and indicate location of use: Home versus in-facility.
Location in Form 26511
++ Expand Worksheet A, Line 6.
++ Revise instructions for Worksheet A1, adding specificity corresponding to item definitions discussed earlier in the preamble.
c. Direct Patient Labor Allocation Currently, the cost report does not stratify full-time equivalent FTE hours for direct patient care staff by dialysis modality. It also does not include several job classifications that are commonly found in present-day ESRD
facilities.
At present, the statistical basis for allocating direct patient care costs is hours of service as seen in Worksheet B1, Column 5. Using this metric and allocating resource or labor use proportionally by labor hour independent of labor type can result in miscalculation of labor costs by modality. For example, if labor for the provision of home dialysis is on average more expensive than labor for in-facility hemodialysis, then a strict by-hour cost allocation will result in a calculation of home dialysis labor costs that is less costly per-hour than in practice.
Suggestions have included that by substituting FTE for hours for each appropriate direct patient care labor category, and using labor categories that more accurately reflect current staffing patterns in ESRD facilities, any potential misrepresentations of relative labor costs across modalities can be remedied.
To this end, CMS has received a suggestion to consider the use of Bureau of Labor Statistics BLS occupational categories for outpatient care centers to remedy this situation, as it would provide up-to-date job classifications that the comment believes would better
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correspond to staffing patterns in ESRD
facilities than the currently used Inpatient Prospective Payment System job categories. Selecting BLS
occupational categories for outpatient care centers could be added or substituted in Lines 2331 on Worksheet S1 of CMS Form 26511 to reflect current staffing patterns, and columns could be added to separately report home dialysis FTE and in-facility dialysis FTE for each relevant occupational category. Additional labor categories might include registered nurses with varying credentials, dieticians, pharmacists, and nurse practitioners and other intermediatelevel providers, as appropriate.
d. Managerial and Administrative Labor Allocation The data contractor and TEP panelists discussed Medicare cost reports nondirect patient care positions, specifically the current managerial and labor allocation. They made recommendations for differentiating high-cost management from lower-cost administrative and clerical functions, which included a set of potential revisions to bring management and administrative labor categories up to date using occupational categories that reflect current usage in dialysis facilities.
As with the direct patient labor allocation above, suggestions include the use of BLS occupational categories for outpatient care centers that correspond to the roles employed in contemporary dialysis facilities.
Suggested additions to these job categories might include business and financial operations personnel, office and administrative workers, facility support workers, and programmers and analysts. With more accurate data, it may be possible to determine how management and administrative costs are differentially allocated across facilities by region and treatment-type specialization. These suggested changes to managerial and administrative job categories would be made to Worksheet S1, Lines 3134.
e. Supplies and Laboratory Services While composite rate and separately billable drug costs are differentiated on the cost report, supplies and laboratory tests are not differentiated. Supplies comprise approximately 10 percent of composite rate costs. To bring uniformity to the reporting of drugs, laboratory tests, and supplies, we have received suggestions that supplies and laboratory tests be similarly stratified.
These costs are currently reported on Worksheet B/B1. Specifically,
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