MACRA: Taking Advantage of Improved Outcomes Associated with Home Dialysis

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) went into effect January 1, 2017. MACRA determines reimbursement for physicians receiving Medicare Part B payments in today’s value-based health care system. This new reimbursement structure impacts nephrologists and hospital networks primarily through two Centers for Medicare & Medicaid Services (CMS) quality payment program pathways: Merit-based Incentive Payment Systems (MIPS), which represents the selection for the majority of nephrology practices, and Alternative Payment Models (APMs). MIPS relies on a composite score (CPS) composed of four categories: Quality, Advancing Care Information, Clinical Practice Improvement Activities, and Cost or Resource Use (PY2018) for payment and provides clinicians the flexibility to choose the activities and measures that are most meaningful to their nephrology practice to demonstrate performance.

It is important that physicians utilize the 2017 grace period to build both an understanding of what MACRA means to their practice (for different patient populations with and without end stage renal disease (ESRD)) and ensure their care teams are following those processes critical to achieving superior clinical outcomes. This will allow practices to potentially take advantage of MACRA reimbursement opportunities going forward.

In a broad sense, practice-specific efforts should begin upstream, since the success of patients in the first year of dialysis is determined by the frequency of outpatient department visits and consistency of visits prior to actually starting dialysis. Once patients are ready to begin dialysis, matching specific populations of patients (such as patients under 60 years of age, patients who are employed, students, diabetics, patients with residual renal function, those with decreased ejection fraction, or the elderly) to the best-possible ESRD modality and ensuring they are achieving targeted metrics will be key to success in this new reimbursement system. As such, practices should begin focusing on those patient care decisions and processes that positively drive quality results in tier practices.

Providers and health care teams who manage ESRD patients in the home, on either peritoneal dialysis (PD) or home hemodialysis, have an opportunity to take advantage of the early survival benefit, lower hospitalization rate, improved quality of life and favorable resource utilization that is often achieved with home dialysis. These outcome measurements are critical to consider when formulating a practice-based MACRA strategy.

Proactive MACRA response steps in a home-focused practice include:

1. Providing well-structured pre-ESRD patient education that leads to proper modality determination
2. Implementing urgent-start PD programs that avoid placement of a central venous catheter in favor of a PD catheter
3. Maintaining up-to-date complete ICD-10 patient problem lists
4. Managing care transitions closely to assess whether a modality change is necessary to enhance patient outcomes
5. Achieving the best-possible modality quality metrics

It is important to know your practice data in each of these areas and to understand the MACRA process; this information can be helpful in the development of home dialysis-focused future improvement activities. There are a number of available resources to help you understand the MACRA process, such as CMS’ review of the Quality Performance Category and Dr. Adam Weinstein’s presentation on MACRA for the Renal Physician’s Association.