End-Stage Renal Disease: CMS Should Monitor Access to and Quality of Dialysis Care Promptly after Implementation of New Bundled Payment System

GAO-10-295 Published: Mar 31, 2010. Publicly Released: Apr 30, 2010.
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Medicare covers dialysis for most individuals with end-stage renal disease (ESRD). Beginning in January 2011, the Centers for Medicare & Medicaid Services (CMS) is required to use a single payment to pay for dialysis and related services, which include injectable ESRD drugs. Questions have been raised about this new payment system's effects on the access to and quality of dialysis care for certain groups of beneficiaries, such as those who receive above average doses of injectable ESRD drugs. GAO examined (1) Medicare expenditures for injectable ESRD drugs, by demographic characteristics; (2) factors likely to result in above average doses of these drugs; (3) CMS's approach for addressing beneficiary differences in the cost of dialysis care under the new payment system; and (4) CMS's plans to monitor the new payment system's effects. GAO analyzed 2007 data--the most recent available--on Medicare ESRD expenditures and input from 73 nephrology clinicians and researchers collected using a Web-based data collection instrument. GAO also reviewed reports and CMS's proposed rule on the payment system's design and interviewed CMS officials.

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Recommendations for Executive Action

Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services To help ensure that changes in Medicare payment methods for dialysis care do not adversely affect beneficiaries, the Administrator of CMS should monitor the access to and quality of dialysis care for groups of beneficiaries, particularly those with above average costs of dialysis care, under the new bundled payment system. Such monitoring should begin as soon as possible once the new bundled payment system is implemented and be used to inform potential refinements to the payment system.
Closed – Implemented
CMS has analyzed access to and quality of dialysis care under the bundled payment system for beneficiaries with above average dialysis expenditures. Specifically, in May 2019, CMS examined monthly rates for seven select health adverse advents, such as hospitalization, emergency department use, and heart failure from 2010 through mid-2018 to analyze quality of dialysis care. CMS also examined median and average distances traveled to dialysis facilities for these same years to analyze access to care. For these comparisons, CMS identified above average-cost beneficiaries by two methods-beneficiaries with both Medicare and Medicaid eligibility and beneficiaries in the highest 20 percent risk score--that is, individuals with similar demographic information and the most serious medical conditions. CMS concluded that implementation of the bundled payment system did not appear to have had a detrimental effect on either quality of or access to care for beneficiaries with higher than average expenditures.

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