With its three quality measures related to hemoglobin levels and dialysis adequacy, the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) is a toe in the water for pay-for-performance. As additional measures are added to this model program, though, it has the potential to make a big splash.
“These are such low-hanging fruit areas that I don't think it's going to be very hard for people to hit these standards, so I really don't see this moving the quality ball forward,” said Edward R. Jones, MD, President of the Renal Physicians Association and a nephrologist with Delaware Valley Nephrology & Hypertension, in a phone interview. “I think when new and additional measures come in that may be the case.”
Under this program from the Centers for Medicare & Medicaid Services (CMS), dialysis providers and facilities will see payments docked up to two percent for failure to meet or exceed a certain performance score.
“In some ways it's groundbreaking for CMS in that it's really the first foray into mandatory pay-for-performance,” said Jonathan Himmelfarb, MD, Professor of Medicine, Director of the Kidney Research Institute, and the Joseph W. Eschbach Endowed Chair in Kidney Research at the University of Washington, in a phone interview.
“As is often the case, federal policy starts with the nephrology community and the end-stage kidney disease community in areas that are possibly linked globally to health care change and health care policy.”
Hemoglobin, Urea Reduction Ratio
This first iteration of the Quality Incentive Program applies to payments for outpatient maintenance dialysis items and services provided between Jan. 1, 2012, and Dec. 31, 2012. Although the final rule establishing performance standards and payment adjustments was just issued on Dec. 29, facilities are being judged on care they provided in calendar year 2010, a decision that has stirred some discussion.
“That's the best they can do because they're using claims data,” said Jay Wish, MD, Medical Director of the Hemodialysis Program at University Hospitals Case Medical Center and Professor of Medicine at Case Western Reserve -University School of Medicine, in a phone interview.
“I think eventually when they have real-time data they're going to be able to get a better synchronization of when the data are actually collected and the year for which you're being judged.
“Unfortunately when you're using data that's basically two years old you don't have the opportunity to take the data that you're being judged upon and use it to drive quality-improvement programs. It's basically done-deal data.”
The three measures for this first iteration, which were finalized in a previous rule, are:
* percentage of Medicare patients with an average hemoglobin less than 10.0 g/dL,
* percentage of Medicare patients with an average hemoglobin greater than 12.0 g/dL, and
* percentage of Medicare hemodialysis patients with an average urea reduction ratio (URR) of 65% or greater.
“Many units meet these now, so I don't think it will be a huge stretch to do it,” said Thomas Hostetter, MD, Director of the Division of Nephrology at Albert Einstein College of Medicine and Chair of the American Society of Nephrology Public Policy Board, in a phone interview.
“Since it's coming in with the Prospective Payment System, it will potentially guard against the underuse of erythropoiesis-stimulating agents [ESAs] by weighting the QIP so that the less-than-10 measure has the weight of the other two combined.”
Under the new Prospective Payment System, which went into effect Jan. 1, each dialysis treatment is reimbursed with a single bundled payment that covers all dialysis services, as opposed to the previous system, which paid a composite rate for a defined set of items and services while certain drugs, laboratory tests, and other services were separately reimbursed.
“That's been a concern that with bundling we'll go from one position where perhaps ESAs were overused to the opposite position where they're underused, and I think this final rule is recognizing that risk,” Dr. Hostetter said.
Dr. Wish said he would have liked to have seen one hemoglobin measure instead of two.
“I personally think it would have been better to have one single hemoglobin measure and reward based on the percentage of patients between 10 and 12 rather than penalizing for the patients under 10 and the patients over 12.
“The problem is now that if you try to move your hemoglobin distribution curve so you have fewer patients above 12 you're inevitably going to begin having more patients below 10.”
The issue is further complicated by the use of older data to set the initial performance standard: the lesser of the provider's/facility's performance during 2007 or the 2008 national performance rates.
“To a certain extent the standard of care has changed following for instance the publication of the CHOIR [Correction of Hemoglobin and Outcomes in Renal Insufficiency] and CREATE [Cardiovascular Risk Reduction by Early Anemia Treatment with Epoetin Beta] studies that suggested that high hemoglobin levels may be bad for patients,” Dr. Wish said. “So I think that's part of the problem that you're judging your actual performance in 2010 when the standards of care have changed because of additional knowledge, yet they're using 2008 data as the benchmark, and I think to a certain extent that's not really fair.”
The program also could have disproportionate effects on facilities that treat economically disadvantaged patients, particularly facilities in extremely rural or extremely urban areas, Dr. Himmelfarb noted.
“There are always concerns that facilities that take care of disadvantaged patients who may not achieve quality measures as readily perhaps due to access to medications or other issues may be penalized in a pay-for-performance system, but all things considered I think that they've done a good job with this,” he said.
Information regarding QIP performance, including total performance score, comparisons of the score to the national average, and performance scores for individual measures, must be made available to the public. A certificate showing total score must be provided to each provider and facility, and that certificate must be posted in patient areas.
“I think public reporting is a good thing; transparency in general in health care is a good thing,” Dr. Himmelfarb said.
“A consumer should be able to find out the performance of one facility versus another or one provider versus another, but the information that's involved has to be relatively sophisticated, even if it's presented in a simple format.
“One of the potential concerns with this is public reporting of data that's not well case-mix adjusted may potentially be misleading in some cases, so I think that's the major caveat that I have with this.”
It's unclear what, if anything, CMS will do to make the performance scores meaningful to patients, said Dolph Chianchiano, JD, MPA, Senior Vice President for Health Policy and Research at the National Kidney Foundation.
“I know that they're going to require that dialysis clinics post those scores, but that doesn't necessarily mean that patients will understand what the scores mean and how patients can work with the staff to initiate or contribute to a dialogue with the health care team in their dialysis clinic about how patients can help in the achievement of improved scores going forward.”
Also uncertain is how the money generated from the QIP payment deduction will be used.
“Although we asked and we appreciate that this is a program where Congress indicated that facilities are penalized for poor performance rather than incentivizing facilities by rewarding those that have good performance, which is how every other value-based-purchasing program has been considered by Congress, we were a little disappointed that the Agency didn't say what it was going to do with the penalty money,” said Kathy Lester, JD, MPH, Regulatory Council for Kidney Care Partners (KCP) and a partner with Washington, D.C.-based law firm Patton Boggs. Kidney Care Partners is a coalition of dialysis professionals, patient advocates, and industry members.
“This is an area where KCP as we have looked at it from legal and policy points of view believe the Agency has sufficient authority to be able to take that money and keep it in the ESRD program,” Ms. Lester said.
“One of the ideas that we offered in our comment letter was to have CMS create a reward pool, and so for those entities—facilities or providers—that exceeded expectations they could receive a bonus pool, which would create the incentive that you would want to have in place that rewards high-quality care.”
Good Place to Start
The three measures in the initial set are only the beginning for the Quality Incentive Program.
Measures under consideration by CMS include those related to mineral metabolism, vascular access type, vascular access infections, pediatric anemia (e.g., iron targets), pediatric dialysis adequacy (Kt/V), and fluid management. The agency also intends to eventually replace the URR measure with Kt/V.
“Being an advocate for Fistula First, I would love to see the quality incentive payment also relate to vascular access, not only which kind of access you have but also vascular access complications, for instance, and they're already starting to collect claims data related to catheter-related bacteremia,” Dr. Wish said. “Those are things that clearly have a major impact on patients.
“I think down the road a lot of the other cardiovascular issues in terms of fluid weight gain, fluid weight management, and things like that will ultimately be valuable as potential quality indicators.”
The National Kidney Foundation would like to see measures related to bone and mineral metabolism included in future iterations of the QIP, Mr. Chianchiano said.
“We're very interested in seeing those kinds of measures added to the QIP program in 2013 and beyond, especially because of the risk of undertreatment and also of changes in patterns of prescription that might result from the inclusion of those drugs that do not have an injectable equivalent in the bundled payment system after Jan. 1, 2014.
“As in the Medicare Improvements for Patients and Providers Act, we're interested in seeing measures for iron utilization in dialysis and ultimately very much interested in measures that have to do with patient experience of care and quality of life and functional status of dialysis patients.”
But care must be taken when translating quality-improvement measures into pay-for-performance measures, Dr. Jones noted.
“Measures are fine, except when you're using them for accountability and pay-for-performance it's a little different than when you use the measures for quality improvement,” he said.
“There are some selected measures that I think could change quality outcomes, but a lot of the measures just are not ready for prime time when it comes to pay-for-performance.”
While perfect data is never going to be available, it is important that the measures chosen for the next wave have the best scientific evidence, Dr. Hostetter said. The initial three measures are a reasonable jumping-off point.
“I think it's a good place to start because this is new territory—a pay-for-performance initiative—and so starting modest with indicators that are generally supportable even if not perfectly scientifically supportable seems reasonable,” Dr. Hostetter said.
“We are very interested in how the process goes on henceforth and what new indicators are decided upon.”