National Update NRAA by HC120613184643

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									NRAA Update

Diane Wish
NRAA President
FRAA Annual Meeting
July 16, 2011
Overview

   NRAA Membership and Structure
   Committees
   Industry Involvement
   Priority Issues
   Major Initiative – NRAA HIE
   Future Plans

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NRAA

   Mission:The resource and voice for the
    independent, regional and community
    based dialysis providers
   High level of credibility within the
    industry and with legislators, CMS,
    GAO
    – Impact on small providers is solicited and
      stressed
                                                   3
NRAA Membership

   Change from individual member to
    organization membership
    – Each provider has 1 voting representative
    – Encourage additional members/contacts
   Board – 15 members
    – 5 officers
    – 4 regional directors
    – 6 at-large directors
                                                  4
NRAA Committees
Board members are chair and co-chair
    – Encourage additional participation from the voting
      members and contacts
   Membership
    – Trying to expand, especially hospital based facilities
    – Member surveys
   Finance / Investments
    – Budgets, cash flow
   Political Action Committee
    – Solicit funds                                     5

    – Recommend contributions
NRAA Committees
   Governance / Bylaws / Nominations
    – Important to have new people on the
      Board that reflect membership
   Program
    – Spring meeting
    – Annual meeting
    – Periodic webcasts
   Communications / Website
    – In process of major redesign          6
NRAA Committees

   Industry Liaison
    – Vendor support is essential
    – Foster open communication
    – Advance mutual goals
   Hospital Based Dialysis
    – Excellent resource for hospital providers


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NRAA Committees
   Quality - provide comments and
    educational programming
    – Conditions for Coverage
    – Participation in surveyor training
    – Life Safety Code
   Benchmarking –
    – Data highly confidential
    – Avalere developed tools
        Benchmarking tool - Compare costs to other
         providers
        Bundling tool – was open to all providers
        Bundling pricing tool                        8
NRAA Committees

   NRAA Advocacy Network
    – Grassroots / Advocacy
    – Advocacy Ambassadors
         Special day long training in April
         Members live in states with key legislators
    – Capwiz
         On-line advocacy
    – Mapping project

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      NRAA and ESRD Industry
      Involvement
       National Advocacy
   NRAA – represents small/medium sized providers
   KCC - represents 13 providers provide 85% of pts
   KCP – 33 members represent ESRD industry since
    2003; including the NRAA
    – Members include providers, professional organizations,
      patients and pharma
    – Consistent message by all members provides significant
      credibility with Congress and CMS
    – All 3 working on legislative and regulatory issues
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    – Organization is a model for other healthcare organizations
NRAA and ESRD Industry
Involvement
 National Advocacy
   KCP
    – Operations Committee
       NRAA represents the non-profit organizations
       Maureen Michaels representative in past

       Larry Emerson – current rep. - 2 year term

    – Various work groups
         NRAA participates in all of them


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Kidney Care Partners Initiative
       PEAK Program

Performance Excellence and
 Accountability in Kidney Care
   Goal – Reduce 1st yr mortality 20% by 12/2012
   Patient/Family Engagement Expert Panel
    – 6 Patient Engagement Best Practices and Tools
   Technical/Curriculum Expert Panel
    – 9 Clinically Focused Best Practices and Tools
   Data/Results Expert Panel
    – To release baseline data and methodology
                                                      12
PEAK

Best Practices, Tools and Resources
 Have been rolled out monthly as of
  March 2010
 Great resource for QAPI improvement
  process, staff and patient education
  – www.kidneycarequality.org
  – PEAK Campaign Learning Center


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PEAK

   Preliminary Results
    – Mortality rates at 90 days, 120 days and
      1 yr continue to decrease
          May not reach goal by end of 2012
    – Significant variation between Networks
    – Major issue is catheter use upon initiation
        CKD influence
        Providers need to assure permanent access
         plan upon admission
                                                     14
NRAA and ESRD Industry
Involvement
 National Advocacy
   Legislative – Prime Policy
    – Jerry Klepner
    – Rich Meade
    – Cary Gibson
   Weekly calls with the Board
   Open doors with legislators and regulatory
    agency staff
   Maintain communication with key
    stakeholders                          15
Priority Issues

Bundling
 Transition Adjustor

 QIP

 Oral Drugs

 Bundling Pricer Tool

ESAs
ACOs
                         16
Bundling
Transition Adjustor
   Major victory for ESRD industry
    – Result of collaboration and grassroots
   CMS assumed 43% would opt-in
   Budget neutrality adjustor = 3.1% cut ($7/tx)
   Actually ~92% opted in
   Interim final rule – 0% adjustor 4/1/11
    – ~ .77% adjustor as of 1/1/11
    – Avoids rebilling
   Proposed rule – 0% adjustor in 2012        17
Bundling
Quality Incentive Program,
   QIP
   Proposed rule for payment years 2013
    and 2014 recently released
    – Significant changes due to the recent
      changes in the FDA labeling for EPO
    – Concerns regarding quality care, pt.
      quality of life and financial constraints
    – Issues with the performance standards,
      weighting and payment reductions
                                                  18
QIP
 Proposed Future Indicators
   HGB - % pts >12 g/dL
   Kt/V – HD - % pts >=1.2 PD- % pts >=1.7
   Vascular Access - % pts w/AVF & % pts
    w/catheter >90 days
   Vascular Access Infection Rate - # of months
    where infection reported via V8 modifier
   Standardized Hospitalization Ratio - # of actual
    vs expected hospital admissions
   National Healthcare Safety Network event
    reporting
   Pt. Experience of Care Survey Usage
   Mineral Metabolism Reporting                19
QIP
   Increased transparency

Dialysis Facility Compare
Dialysis Facility Reports
   draft reports just released 7/15/11
   review and comment until 8/15/11
Posted Results

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    QIP
          Comments

   NRAA will comment on the proposed rules
    – Numerous issues to address
    – Comments due August 30, 2011
    – Final rules probably published November 2011




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           Bundling
            Oral Drugs
   Current bundle includes oral drugs in Part D with IV
    equivalents
          Home pts
   2014 all ESRD oral drugs
    – Oral ESRD drugs in Part D without IV equivalents such as
      phosphate binders, and calcimimetics
   Concerns
    – Facilities must dispense drugs and meet state pharmacy regs
      or contract w/pharmacies
    – Proposal grossly underfunded; $14/tx
    – Industry estimates cost ~ $45-75/tx
   GAO study                                               22
Bundling
 Oral Drugs - GAO Study
   NRAA involvement
    –   met prior to study
    –   reviewed draft
    –   stressed the need to appropriately reimburse for costs
    –   described the administrative burden and
    –   impact on independent providers
    –   evaluating ways to help our members to implement this
        rule
   GAO recommends that CMS assess payment adequacy
   ensure availability of reliable data for monitoring
    treatment of mineral and bone disorder.
                                                          23
    Bundling
     Oral Drugs - GAO Study
   GAO cited 3 reasons for including orals
    – Promote more efficient dialysis care
    – Promote clinically appropriate care
    – Improve patient access to the drugs
   GOA warned that inadequate pxs could lead
    to access and quality of care issues
    – CMS has limited data to determine cost
   Limited baseline quality data – Elab
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    – Future CROWNWeb
Bundling
 Medicare Pricer Tool

   CMS’s tool delayed
    – Released July 15, 2011
    – Single patient
   NRAA worked with Avalere to develop
    a multiple patient tool
    – Members only


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National Coverage Decision
 ESAs

    CMS proposed decision memo
     – Will not issue an NCD for ESAs
    NCD for dialysis patients is less
     important since almost 90% of
     providers are bundled
     – Cost and quality incentives are aligned
    Concern re controversy at CMS
     – NCD might be in conflict with the QIP
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Accountable Care
Organizations, ACOs
   Draft rules published March 31, 2011
   ACOs are networks of providers within the
    Medicare system, including physicians, hospitals
    and health systems
   Goal is to improve the quality of care, to
    produce cost efficiencies, with any savings to
    be shared by the government with the ACOs
   Proposed regulation does not consider dialysis
    facilities as eligible providers
   Dialysis providers free to pursue an ACO-type
    model through the Center for Medicare and
    Medicaid Innovation                        27
       Grassroots

   Involvement of constituents is extremely important
   Federal & state legislators pay more attention to
    issues they hear about
   NRAA Advocacy Network – Marc Chow Committee
    Chair
    – Ambassadors – members from key states and districts
   Important to establish relationships proactively
    – Tour dialysis facilities
    – Easier to make an “ask” when issues are known
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Federal and State Budget
Issues
   Federal Government shutdown was
    narrowly averted
    – Fiscal year (FY) 2011 budget approved
   The budget will cut $38.5 billion, using
    FY10 spending as a baseline
   Future budgets will include cuts in
    Medicare and Medicaid
   Federal and state budget deficits will
    impact ESRD facilities
   Federal debt ceiling current issue        29
           CROWNWeb
            Background
        CMS approved only 3 LDO batch submitters
        All others required to manually submit
        Manual submission: time intensive, subject
         to errors, very expensive
        NRAA pleaded with CMS to allow providers
         to batch submit
     – Many providers invested in EMRs
        CMS told NRAA no due to lack of resources
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       CROWNWeb
        Background
 NRAA proposed to act as a clearinghouse to
  support non-LDO providers to limit # of
  batch submitters
 CMS was sympathetic to NRAA concerns
 NRAA offered opportunity to pilot new
  technology
    – CMS does not want to add any more batch
      submitters using current technology; it may be
      abandoned in future
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         Overview of NRAA
         Production Pilot Project
    NRAA has been working with CMS to allow SDOs
     and MDOs to electronically submit CROWNWeb
     data to CMS

    NRAA as a Health Information Exchange (HIE) will
     serve as a clearinghouse to receive the required
     CROWNWeb data from any willing dialysis provider
     regardless of the type of EMR

    NRAA HIE to develop a sustainable Business Model
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NHIN Chain of Trust & Foundation




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           Overview of ESRD
           Submission and Feedback
                                                                 Submit
                                                                 Quality
                  Submit Data              Submit Data          Measures
         Dialysis               NRAA HIE                 CMS                CMS
         Facilities                          Exchange Gateway
                                Gateway                                     ESRD
                                                                Feedback   Systems
                                             Feedback




               End Users may
                   access
                Feedback as
                  needed




     NRAA as a Health Information Exchange (HIE) will serve as the
      intermediary to electronically submit data to CMS for the ESRD
      Program.
     Currently this is a production pilot, limited in scale to just NRAA as
      an HIE.                                                           34
    34Bi-directional exchange of data.
                                                          34

        Overview of NRAA
        Production Pilot Project
   NRAA HIE Services will include
     assisting facilities to establish initial connectivity
     ongoing help desk and
     operational support
   This production pilot will establish proof of
    concepts
   NRAA will submit the same set of data elements that
    comes in via batch from LDOs, same data that is
    collected via CROWNWeb.
                                                               35
     NRAA HIE
      Process
   NRAA hired an IT HIE consultant to
    coordinate the process
    – Works with the HIE Board Committee
   NRAA HIE Technical Advisory Group, TAG,
    established, includes all EMR vendors,
    interested provider IT staff
   NRAA HIE Consultant is the primary contact
    with CMS
                                            36
    NRAA HIE
     Timeline
   NRAA solicited an HIE RFP
     Board approved One Health Port
   One Health Port
     Washington State HIE, public utility model
         Open business model and transparency into their
          books
     10+ years in business
     Experience connecting to the NHIN/CMS
      gateway for another client
     Recipient of an ONC HIE grant ($11.7M)           37
NRAA HIE
   Timeline
   NRAA HIE consultant & HIE provider
    continue to work with CMS
   Each EMR vendor to have 1-2
    facilities included during the pilot
   EMR vendors will be phased in
    during the testing period

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NRAA HIE
  Cost
   One Health Port - Lowest cost and
    flexible to meet NRAA needs
   Pricing now yet finalized – goal to
    minimize costs to providers
   One time initial cost
    – Based upon organizational revenue tiers
   Annual subscription fee
    – No transaction fees
    – Hopefully in the $.05-.10/tx range        39
NRAA HIE
 Timeline
   Goal for all EMR vendors to
    complete testing with a few facilities
    by end of 1Q 2012
   All data submitted will be discarded
   Target timeline for national roll-out
    of CROWNWeb and the NRAA HIE
    2Q 2012
                                         40
NRAA HIE
 Management
   NRAA Board decided to have the HIE
    under the NRAA GPO
    – To protect the not-for-profit status
   HIE open to all providers with an EMR
    – Future phase – To work transmit lab
      results to providers without an EMR



                                             41
    NRAA
      Management
   NRAA to hire a full-time Executive Director
    – Chief Operating Officer
   Provide continuity and service for NRAA
    and NRAA GPO
    – ED will report to Boards through Chairs
    – Active recruitment process through 8/15/11
    – Content expert; BS/BA, 5+ years ESRD
      management experience
    – Goal to hire by annual meeting in October
                                               42
NRAA
  Future Initiatives
   With new Executive Director NRAA plans
    to add services which add value to
    members
    – NRAA HIE administration
    – Possible ideas
       Group insurance cooperative
       Negotiate payor contracts

       Contracting for disposable supplies & equipment

       Sponsor/coordinate targeted workshops and/or
        other educational events                    43
       Summary

   NRAA is the resource and voice for the
    independent, regional and community based
    dialysis providers
    – Has credibility
    – Impact on non-LDOs is solicited
    – Actively involved and collaborative
    – Evolving to meet changing needs of membership
   NRAA HIE is a major achievement for all non-
    LDO providers                                 44
NRAA Meetings


   2011 Annual Conference
   October 5 - 7, 2011
   New Orleans, LA
    – New Orleans Marriott
   Check NRAA website for details
    – www.nraa.org
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