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Federal Register / Vol. 86, No. 129 / Friday, July 9, 2021 / Proposed Rules
Less than 4,000 treatments 4,000 to 9,999 treatments 10,000 or more treatments Unknown
643

28.8

-0.1%

1.0%

0.9%

2,0ll
108.4

0.0%

1.0%

1.0%

2,525

167.2

0.0%

1.0%

1.0%

68

1.9

0.0%

1.0%

1.0%

Less than2%
5,247
306.3
0.0%
1.0%
1.0%
Between2%
and 19%
0 0.0
0.0%
0.0%
0.0%
Between20%
and49%
0 0.0
0.0%
0.0%
0.0%
More than 50%
0 0.0
0.0%
0.0%
0.0%
1Includes hospital-based ESRD facilities not reported to have large dialysis organization or regional chain ownership.
2Includes ESRD facilities located in Guam, American Samoa, and the Northern Mariana Islands This information should not be deleted.

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Column A of the impact table indicates the number of ESRD facilities for each impact category and column B
indicates the number of AKI dialysis treatments in thousands. Column C
shows the effect of the proposed CY
2022 wage indices. Column D shows the effect of the proposed CY 2022 ESRD
PPS payment rate update. The proposed ESRD PPS payment rate update is 1.0
percent, which reflects the proposed ESRDB market basket percentage increase factor for CY 2022 of 1.6
percent and the proposed productivity adjustment of 0.6 percent.
Column E reflects the overall impact, that is, the effects of the updated wage index and the payment rate update. We expect that overall ESRD facilities would experience a 1.0 percent increase in estimated payments in CY 2022. The categories of types of facilities in the impact table show impacts ranging from an increase of 0.0 percent to 1.6 percent in their CY 2022 estimated payments.
b. Effects on Other Providers Under section 1834r of the Act, as added by section 808b of TPEA, we propose to update the payment rate for renal dialysis services furnished by ESRD facilities to beneficiaries with AKI. The only two Medicare providers and suppliers authorized to provide these outpatient renal dialysis services are hospital outpatient departments and ESRD facilities. The patient and his or her physician make the decision about where the renal dialysis services are furnished. Therefore, this proposal will have zero impact on other Medicare providers.

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c. Effects on the Medicare Program We estimate approximately $52
million would be paid to ESRD facilities in CY 2022 as a result of patients with AKI receiving renal dialysis services in the ESRD facility at the lower ESRD PPS
base rate versus receiving those services only in the hospital outpatient setting and paid under the outpatient prospective payment system, where services were required to be administered prior to the TPEA.
d. Effects on Medicare Beneficiaries Currently, beneficiaries have a 20
percent co-insurance obligation when they receive AKI dialysis in the hospital outpatient setting. When these services are furnished in an ESRD facility, the patients would continue to be responsible for a 20 percent coinsurance. Because the AKI dialysis payment rate paid to ESRD facilities is lower than the outpatient hospital PPSs payment amount, we would expect beneficiaries to pay less co-insurance when AKI dialysis is furnished by ESRD
facilities.
e. Alternatives Considered As we discussed in the CY 2017 ESRD
PPS proposed rule 81 FR 42870, we considered adjusting the AKI payment rate by including the ESRD PPS casemix adjustments, and other adjustments at section 1881b14D of the Act, as well as not paying separately for AKI
specific drugs and laboratory tests. We ultimately determined that treatment for AKI is substantially different from treatment for ESRD and the case-mix adjustments applied to ESRD patients
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may not be applicable to AKI patients and as such, including those policies and adjustment would be inappropriate.
We continue to monitor utilization and trends of items and services furnished to individuals with AKI for purposes of refining the payment rate in the future.
This monitoring would assist us in developing knowledgeable, data-driven proposals.
3. ESRD QIP
a. Effects of the PY 2022 ESRD QIP on ESRD Facilities The ESRD QIP is intended to prevent reductions in the quality of ESRD
dialysis facility services provided to beneficiaries. Although the general methodology that we use to determine a facilitys TPS is described in our regulations at 42 CFR 413.178e, we are proposing to codify special scoring policies for PY 2022 at 42 CFR
413.178h. Under these proposed regulations, we would calculate measure rates for all measures but would not calculate achievement and improvement points for any measures.
We would also not calculate or award a TPS for any facility. Finally, we would not reduce payment to any facility for PY 2022.
If these policies are finalized as proposed, we believe there will be no effects of the PY 2022 ESRD QIP on ESRD Facilities, as no facilities will receive a TPS or payment reductions for PY 2022.

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