AKI D Inpatient Problem Outpatient Solution. Jeff Giullian, MD MBA Renal Physicians Association Annual Meeting March 2017

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1 AKI D Inpatient Problem Outpatient Solution Jeff Giullian, MD MBA Renal Physicians Association Annual Meeting March 2017

2 Today s Agenda Historical Background Epidemiology Rules and Regulations Dollars and Sense What lay ahead? Best Practices

3 Timeline Trade Bill CMS stops paying directly for AKI dialysis facilities CMS stops paying for non ESRD care at dialysis facilities CMS will cover AKI at dialysis facilities 2003 OPPS Pays for non routine ESRD (hospital outpatient) US Nat l ESRD Program

4 Today s Agenda Historical Background Epidemiology Rules and Regulations Dollars and Sense What lay ahead? Best Practices

of all AKI, 70% of ICU Sepsis/Hypotension/Reduced renal perfusion

5 Broadly, 2 types of patients: Prior known CKD (approximately 1/8) Prior unknown or non CKD Acute Tubular Necrosis Leading Cause 45% of all AKI, 70% of ICU Sepsis/Hypotension/Reduced renal perfusion Drugs/Nephrotoxins Severe volume depletion AKI Etiologies (In General)

6 Figure 5.3 Unadjusted rates of first hospitalization with AKI, per 1,000 patient years at risk, by age and year, (b) Clinformatics (aged 22+) AKI: Overview KDIGO: Abrupt decrease in kidney function over 7 days or less per million population 7 18% (or 20%) of hospitalized 50% of ICU 2 million deaths annually Data Source: Special analyses, Medicare 5% sample and Clinformatics. (a) Age as of January 1 of specified year. All patient years at risk for Medicare patients aged 66 and older who had both Medicare Parts A & B, no Medicare Advantage plan, no ESRD by first service date from Medical Evidence form, and were alive on January 1 of year shown. Censored at death, ESRD, end of Medicare Part A & B participation, or switch to Medicare Advantage program. (b) All patient years at risk for Clinformatics commercial insurance patients aged 22 and older who were enrolled in the plan, did not have diagnoses of ESRD, and were alive on January of year shown. Abbreviation: AKI, acute kidney injury; ESRD, end stage renal disease Annual Data Report, Vol 1, CKD, Ch 5 6

7 Clinical Nuances Wide variability in the incidence and rate of recovery of renal function. No guidelines to determine how or when an AKI D patient has transitioned to ESRD. No evidence exists that ESRD clinical practice guidelines (i.e., anemia management, MBD) are applicable to AKI patients. Loose definition of AKI may impact how nephs will categorize patients going forward Jorge Cerdá et al. CJASN 2008;3: by American Society of Nephrology

8 AKI D Doubling Hsu, RK et al Temporal changes in incidence of dialysis requiring AKI JASN ; 2013

10 Discharges: AKI vs No AKI AKI No AKI Medicare Discharges, USRDS 2014

11 Discharges: AKI vs No AKI AKI Fewer Home Discharges More Death No AKI Medicare Discharges, USRDS 2014

12 Dialysis Location Advantage Disadvantage Inpatient Hospital based unit Continuity of Care Convenience Acute care setting Status quo LOS, Cost, Complications, Capacity Capacity & limited availability Admissions requirement Cost LTAC or Rehab Outpatient ESRD Center Convenience Ancillary services Cost Location Heung, M et al CJSAN 10: Must qualify Cost Lack of AKI specific protocols Pressure for discharge Fewer ancillary services Fewer physician visits

13 More Epidemiology 170,000+ AKI D patients annually 4 5% of all ICU patients require dialysis ICU census growing, currently over 5 million admissions Mortality declining 5 20% dialysis dependent at discharge Other references: 10 30% Cost $10 Billion/year 2015 DaVita HealthCare Partners Inc. All rights reserved. Proprietary and confidential. For internal use only.

patients requiring dialysis among those with a first AKI hospitalization Data Source: Special analyses, Medicare 5% sample.

14 Figure 5.1 Percent of Medicare patients aged 66+ (a) with at least one AKI hospitalization, and (b) percent among those with an AKI hospitalization that required dialysis, by year, (b) Percent of patients requiring dialysis among those with a first AKI hospitalization Data Source: Special analyses, Medicare 5% sample. (a) Percent with an AKI hospitalization among all Medicare patients aged 66 and older who had both Medicare Parts A & B, no Medicare Advantage plan, no ESRD by first service date from Medical Evidence form, and were alive on January 1 of year shown. (b) Percent of patients receiving dialysis during their first AKI hospitalization among patients with a first AKI hospitalization. Dialysis is identified by a diagnosis or charge for dialysis on the AKI hospitalization inpatient claim or a physician/supplier (Part B) claim for dialysis during the time period of the AKI inpatient claim. Abbreviations: AKI, acute kidney injury; ESRD, end stage renal disease Annual Data Report, Vol 1, CKD, Ch 5 14

15 Epidemiology of AKI 20% of hospitalized patients develop AKI. Most recover before the need for dialysis, but 1 2% of total patients require dialysis. Of individuals with AKI D: ~50% will die in the hospital ~25% will recover renal function ~25% (10 30%) will require dialysis upon hospital discharge Some will be deemed ESRD Others may still regain renal fxn eventually (Cerda et al. CJASN 2015).

and did not have any claims with a diagnosis of CKD in the 365 days prior to the AKI.

16 Medicare: 1 year after AKI (Death Censored) Data Source: Special analyses, Medicare 5% sample. Medicare patients aged 66 and older who had both Medicare Parts A & B, no Medicare Advantage plan, did not have ESRD, were discharged alive from a first AKI hospitalization in 2012 or 2013, and did not have any claims with a diagnosis of CKD in the 365 days prior to the AKI. Renal status after AKI determined from claims between discharge from AKI hospitalization and 365 days after discharge. Stage determined by 585.x claim closest to 365 days after discharge; ESRD by first service date on Medical Evidence form. Abbreviations: AKI, acute kidney injury; CKD, chronic kidney disease; ESRD, end stage renal disease Annual Data Report, Vol 1, CKD, Ch 5 16

17 (Cerda et al. CJASN 2015). In Hospital AKI

18 Chawla, LS et al Nature Reviews: Nephrology 2017 epub Feb 2017 AKD: New term coined to address the grey zone between AKI and CKD/ESRD

19 St. Elsewhere Community 200 Bed Hospital 2,000 AKI

20 Today s Agenda Historical Background Epidemiology Rules and Regulations Dollars and Sense What lay ahead? Best Practices

21 SSA Amendment (TPA/TAA) Dialysis services furnished on or after January 1, 2017, by a renal dialysis facility to an individual with acute kidney injury. (paraphrase) In the case of renal dialysis services to an individual with AKI, the payment shall be the base rate for ESRD services Applicable geographic adjustment m May be adjusted by the Secretary on a budget neutral basis. (paraphrase) No limitation on treatments monthly

22 AKI: Definition For payment, the term Acute Kidney Injury refers to: an individual who has acute loss of renal function and does not receive renal dialysis services for ESRD.

separate payment for typical renal services Dialysis drugs

23 Payment to hospital based and freestanding ESRD facilities. PPS base rate adjusted by the wage index/geography No separate payment for typical renal services Dialysis drugs EPO/ Biologic Renal labs Supplies No $0.50 to the Network CMS Rules

24 Limitations? Isolated UF: Peritoneal dialysis Home HD: NOT reimbursed! There are no billing limits for treatments during a monthly billing cycle. However, there will only be payment for one treatment per day across settings; except in the instance of uncompleted treatments. No explicit limitations to seeing patient in office (E/M billing)

25 Today s Agenda Historical Background Epidemiology Rules and Regulations Dollars and Sense What lay ahead? Best Practices

26 Eyeballs-on-Your-Site.jpg Doc Payments Used to report inpatient hemodialysis or outpatient hemodialysis performed on non ESRD patients $73 $ Visits during same session $107 $118 G codes TBD Feds will be watching Picture of Eye Balls Give info on RVU,e tc

27 90935 Medicare Administrative Contractor (MAC) site of service exclusion preventing use of CPT code for AKI services provided in the dialysis facility has been removed. Nephrology practices should be prepared to appeal possible denials for outpatient AKI services billed with CPT code until the guidance is formalized.

28 JV Implications: Beneficial? Extra patients AKI patients/facility 25% 35% of facilities Could account for 2% of patient population Potentially fewer drugs More labs Same amount of supplies Similar IDT workload No network costs No additional fixed costs Could a JV make a few $1,000 extra margin per year? Feasible, but mostly just beneficial to patients/hospitals

29 Cohorts Patient Cohorts Description Outpatient Hospital LTAC Low Comorbid D/c sooner Likely to recovery Low impact Fewer ESRD Reduce LOS Fewer admissions High Comorbid Require higher level of care (i.e, wound, antibiotics) Unlikely unless home health No impact to LOS Minimal impact on admissions, could reduce LOS Prolonged Hospitalization Currently considered ESRD May now label AKI Fewer 2728 on day 1 No impact to LOS No impact Extended Criteria Patients could come directly from outpatient world Wild card Close Fed monitoring? Unclear impact Fewer Hosp admissions? No impact

30 Extended Criteria AKI Will we begin to see new cohorts of patients? CHF with CKD, HRS, Chemo CKD with temporary AKI Will patients bypass the hospital? Unlike a SNF, no mandate for 3 hospital days Could use on short term basis Will we see broader use of nephrotoxic agents?

31 Abuse Appropriate Inappropriate utilization Push the envelope with IV contrast, chemo, etc Dialysis for ultrafiltration Reduce hospitalizations Reduce LTAC Allow for broader use of therapies

32 Today s Agenda Historical Background Epidemiology Rules and Regulations Dollars and Sense What lay ahead? Best Practices

33 LDO Data: AKI Treatment Average Age: 61 Average time to 2728: 51 days

34 AKI D Outpatient Treatments Rising

35 Lab Draws: LDO Data

36 Complications High likelihood of readmission Hospitals will need to understand this Docs and patients will need to accept this Does not count against SHR for Publically Reported Data (5 Star) Mortality These patients remain unstable Will not count against SMR for Publically Reported Data (5 Star)

37 Recurrent AKI Hospitalization 2016 Annual Data Report, Vol 1, CKD, Ch 5 37

38 Death and/or ESRD following AKI: Medicare 2016 Annual Data Report, Vol 1, CKD, Ch 5 38

39 Avoidable Consequences? New cohorts of AKI patietns? Dialysis beyond renal recovery Requires pre emptive vigilance Transition to ESRD without proper access/education Requires pre emptive vigilance Could be system gaming risk Joint effort from MD, IDT and family Likely will require more frequent rounding by MD

40 Today s Agenda Historical Background Epidemiology Rules and Regulations Dollars and Sense What lay ahead? Best Practices

41 Consensus Guidelines (opinion based) Recovery from RRT: Sustained independence x 14 days Renal labs 72 hours (and not more than 7 days) following last RRT Interval for subsequent evaluations based upon clinical judgment For AKI D patients in outpatient setting: Weekly assessment of pre dialysis creatinine Regular assessment of 24 hour urine collection for volume and creat/urea cl. Personalized approach that maximizes likelihood of recovery Avoidance of excessive fluid removal Chawla, LS ADQI Consensus Report. Nature Reviews: Nephrology Feb 2017

42 Best Practices Active Monitoring recommended Weekly BUN & Creatinine (pre HD) Urine output measurement and Intradialytic weight gain (record like VS) egfr monitoring by Medical Director Unknown optimal frequency of physician rounding Target Weight (Less Aggressive) Hypotension risk for second ischemic insult Bioimpedance in the future? Stop Dialysis outright vs taper or wean? Anemia management, MBD mgt?

43 Predictors of Survival Pre hospital BUN & creatinine Higher might be better Age Hospital LOS Malignancy UOP Overall recovery status at discharge. At 90 days

44 Knowledge Gaps Can we affect 90 day mortality? What % renal recovery should we expect? When is it time to call ESRD? When is it time to educate? When is it time to place access? What is the right cadence for lab monitoring? Blood: BUN/Creat, Kt/V, Minerals Urine studies: 24 hour Creatinine/urea clearance Urine output measurements

45 More Knowledge Gaps Cutoff of time before ESRD? Minimum vs Maximum? 6 12 weeks seems fair (from 1 st dialysis, from entering DaVita?) Should prior GFR/CKD status matter? Should we have a tiered protocol for access planning? When do we start Kidney Smart or Modality discussions? When deemed ESRD, does 90 day timer start? Access education and plan prior to 2728? Publically reported data: QIP & 5 Star

46 What Metrics, When? Patient volumes CMS will be watching closely Etiology Does this impact recovery prediction? Co morbidities Higher risk of death and readmission Recovery time Fair to compare docs? Mortality rates Same question? Can we standardize? Re hospitalization rates Ditto Other?

47 Standing Orders? Standardization might reduce variation in treatment Weekly/biweekly lab panel with regular reports to doc 24 hr Urine Urea/Creatinine Clearance every two weeks Monitor creatinine, consider algorithm for holding HD Phos, PTH, Albumin??? What is the utility? Facility s Governing Body most likely reviewed and made a decision regarding their use.

48 Standing Orders? Standardization might reduce variation in treatment Weekly/biweekly lab panel with regular reports to doc 24 hr Urine Urea/Creatinine Clearance every two weeks Monitor Δ creatinine, consider algorithm for holding HD Phos, PTH, Albumin??? What is the utility? Work with facility Governing Body

Chapter 5: Acute Kidney Injury

Chapter 5: Acute Kidney Injury Introduction In recent years, acute kidney injury (AKI) has gained increasing recognition as a major risk factor for the development of chronic kidney disease (CKD). The