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Federal Register / Vol. 86, No. 213 / Monday, November 8, 2021 / Rules and Regulations
health, and home medical equipment, in addition to topics that are unique to this care setting and patient population. No existing survey touches on all aspects of this distinctive experience. Commenters asked CMS to consider including topics specific to dialysis care at home, such as patient training on equipment, supplies, and safety, and communication with and access to the patients care team. According to commenters, CMS could convene a Technical Expert Panel TEP to develop and test a tool to measure the patient voice in their treatment with home dialysis that would include satisfaction, patient activation, quality of life and economic impact of the treatment at home.
Several commenters commented there are already private-sector efforts to develop a survey tool to measure home dialysis patient experience. Commenters encouraged CMS to work closely with these efforts, and to actively support the psychometric testing and validation necessary to ensure that there is a valid and reliable instrument that can be utilized broadly across providers in assessing the experience of home dialysis patients. Commenters specifically mentioned that any Innovation Center effort should complement and not replicate potential efforts to leverage the Home Dialysis Care Experience Home-DCE
instrument developed and initially tested by the University of Washington.
Commenters further expressed hope that this measure will eventually be tested more broadly and be submitted to NQF
for endorsement and use in the CMS
ESRD QIP.
Several commenters mentioned that the survey response rate for ICH CAHPS
has declined significantly in recent years. Therefore, the commenters recommended that any patient experience measure CMS uses should impose minimal burden on patients and providers. In addition, commenters noted that there is a critical need to develop and implement a patient experience tool that does not further health inequities. Lastly, commenters recommended that any home dialysis patient experience measure CMS
implements should be relevant to other CMS programs, such as the ESRD QIP.
Some commenters suggested that a new measure should address the following areas: Ease of use of their modality/device; patient/provider burden in self administration or helping support a loved one; sense of support from the care team.; sense of respect and value from the care team; and communication with the care team. One commenter recommended including
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three specific questions in a new home dialysis patient experience measure.
The first is if the patient previously received in-center dialysis, does the patient have better quality of life on home dialysis? The second is is the patient on home dialysis more able to engage in activities of daily living ADLs? The final question is are dialysis facility staff supportive for patients on home dialysis?
Some commenters suggested additional mandatory measures in the ETC Model. Commenters suggested an advance care planning measure specifically because it is critical for patients and clinicians to define goals of care. Commenters also suggested measures regarding palliative care access and utilization because there is mounting evidence that ESRD patients who have access to or are enrolled in palliative care programs have better outcomes and have more support for treatment choices. Lastly, commenters suggested a measure specific to timely and appropriate referral to hospice to encourage timely and appropriate referral to hospice. The commenters recommended that this measure should also provide documentation of include evidence of goals of care and advance care planning.
With regard to reporting quality outcomes, commenters supported transparency for beneficiaries attributed to ETC Participants. Commenters suggested that reporting of quality outcomes occur annually in order to be consistent with the ESRD QIP timeline.
Commenters also recommended the quality outcomes be available via a website, as well as posted at each facility in the ETC Participants aggregation group. Specifically, because the ETC Model is focused on aggregation at the HRR level, commenters recommended that the data should be at that aggregated level rather than at the individual ETC Participant level.
Response: We appreciate all the comments and interest in this topic and believe that this input is very valuable in the continuing development of the quality measurement efforts for the ETC
Model. We will continue to take all concerns, comments, and suggestions into consideration.
VI. Requests for Information A. Informing Payment Reform Under the ESRD PPS
Over the last several years, CMS, in conjunction with its contractor, has been conducting research, including holding three technical expert panels TEPs, to explore possible
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improvements to the ESRD payment model. Additionally, in the CY 2020
ESRD PPS proposed rule 84 FR 38398
through 38400, CMS invited further comment on a number of topics, including expanding the outlier policy to include composite rate drugs, laboratory tests and supplies; reporting the length of each dialysis session directly on the ESRD claim; patient characteristics which contribute significantly to the cost of dialysis care;
and improving the quality of facilitylevel data as reflected in the Medicare cost report. Stakeholders have asked CMS to explore a refined case-mix adjustment model for the ESRD PPS, stating that the existing case mix adjustors may not correlate well with the current cost of dialysis treatment.
Accordingly, in the CY 2022 ESRD
PPS proposed rule 86 FR 36398
through 36409, CMS included a detailed request for information RFI on several topics in order to inform payment reform under the ESRD PPS.
Those topics included six focal areas:
1 The LVPA payment methodology; 2
calculations for the case-mix adjustment; 3 the calculation for the outlier payment adjustment; 4 the current pediatric dialysis payment model; 5 modifications to the pediatric, the ESRD PPS and the hospital cost report; and 6 payment for home dialysis for Medicare beneficiaries with acute kidney injury. For each topic, we provided background information, reviewed current issues and stakeholder concerns, described suggestions that we received, and included specific requests for information. Although we are not presenting that information again in this final rule, we refer readers to the complete discussion in the CY 2022
ESRD PPS proposed rule, 86 FR 36396
through 36409.
We received numerous public comments in response to our RFI on payment reform under the ESRD PPS, including from large, small, and nonprofit dialysis organizations; an advocacy organization; a coalition of dialysis organizations; a large non-profit health system; an independent commenter; and MedPAC. A high level description of these comments is included below. We will provide more detailed information about the commenters recommendations in a future posting on the CMS website located at the following link: https
www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/ESRDpayment/
Educational_Resources.

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