Fact Sheets

MEDICARE PROPOSALS FOR NEW REQUIREMENTS FOR THE ESRD QUALITY INCENTIVE PROGRAM, INCLUDING FOR PAYMENT YEAR 2015

OVERVIEW:

On July 2, 2012, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would update payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after Jan. 1, 2013.   The proposed rule also proposes changes to the ESRD Quality Incentive Program (QIP) that provides payment incentives to dialysis facilities to improve the quality of dialysis care.  Under the QIP, facilities that do not meet or exceed the specified total performance score with respect to quality measures established in regulation receive a reduction in their payment rates under the ESRD PPS.

In addition, the proposed rule proposes to codify in regulations the reductions in bad debt payments for all Medicare providers eligible for bad debt reimbursement that were mandated by the Middle Class Tax Extension and Job Creation Act of 2012.

BACKGROUND:

The ESRD QIP, which adjusts payments to dialysis facilities based on their performance on measures of quality, builds upon longstanding efforts by CMS to improve the quality of dialysis services furnished to people with Medicare.  The proposed rule for calendar year 2013 proposes to update requirements for the QIP, including the measures and scoring methodologies that would affect payments to dialysis facilities in payment year (PY) 2015. 

With respect to the PY 2015 QIP, the proposed rule proposes to adopt new clinical and reporting measures, as well as expand the scope of two reporting measures currently included in the ESRD QIP, to encompass a broader range of issues faced by patients who receive dialysis care and to address concerns about the quality of life experienced by patients on dialysis.

PROPOSED MEASURES AND WEIGHTING FOR PY 2015 QIP

For PY 2015 payment determination, CMS proposes a total of 11 measures—seven clinical measures and four reporting measures. Clinical measures assess the quality of care provided to individual patients using facility performance on specific clinical indicators. Reporting measures assess whether a facility has reported quality-of-care data as outlined in rulemaking to support quality improvement efforts. 

The four proposed reporting measures would capture information about how the facility:

• Manages patients’ anemia, a common side-effect of hemodialysis;
• Reports dialysis infection events to the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN);
• Monitors patients for mineral metabolism abnormalities in phosphorous and calcium levels; and
• Surveys patients to learn about their experiences of care.

The proposed anemia management reporting measure is new, while the NHSN and mineral metabolism reporting measures are expanded from their introduction for the PY 2014 QIP. Furthermore, the proposed patient experience of care measure remains unchanged from PY 2014, and remains tied to the In-center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) survey instrument.

CMS is proposing to adopt a new Kt/V Dialysis Adequacy measure topic and retain the Vascular Access Type measure topic, each of which are composed of multiple measures.  For purposes of calculating the total performance scores (TPS), CMS proposes to weight the individual measure score(s) applicable to a given facility within a measure topic to create a single score for the measure topic. 

CMS is proposing to weigh individual scores for the reporting measures that apply to a given facility equally to make up 20 percent of the facility’s TPS.

A complete list of measures proposed for the PY 2015 ESRD QIP is available in theAppendix to this fact sheet.

DETERMINING TOTAL PERFORMANCE SCORES FOR PY 2015 QIP

In the CY 2013 proposed rule, CMS is proposing to calculate TPSs for PY 2015 using a similar methodology as was adopted for PY 2014 in the CY 2012 ESRD PPS final rule. Each facility would receive a TPS between 0 to 100 points.

CMS uses clinical and reporting measure scores alike to calculate each facility’s TPS. To calculate the minimum TPS required to avoid receiving a payment reduction, however, CMS proposes to use only clinical measure scores, and to set those scores at the performance standard, which is based on the national performance rate (defined as the 50th percentile of national facility performance in Calendar Year 2011).

Under CMS’ proposal, facilities would earn points on applicable clinical measure topics by comparing their performance during 2013 to: 1) the a national standard based on 2011 data (the “achievement score”); or 2) facilities’ own performance during 2012 (the “improvement score”). CMS would then apply the higher of the two scores when computing the TPS.

CMS is proposing to apply a measure rate adjustment to the clinical measure topic scores of facilities that report between 11 and 25 eligible cases per month­ to encourage quality improvement in these facilities and measure their performance accurately.

CMS is proposing that facilities will receive a TPS as long as they are eligible for at least one clinical measure and one reporting measure.

CMS is proposing to reduce payments to facilities in PY 2015 that do not meet or exceed a minimum total performance score.  CMS is proposing to impose percent payment reductions of 0.5 percent for facilities whose TPS falls below the minimum total performance score by up to 10 points; 1.0 percent for facilities whose TPS is 11 to 20 points below the minimum; 1.5 percent for facilities that score 21 to 30 points below the minimum; and 2.0 percent for facilities whose TPS is more than 30 points below the minimum.

ADDITONAL QIP-RELATED PROPOSALS

CMS is proposing to clarify existing regulations that govern how facilities communicate with their patients about the ESRD QIP.  In particular, the proposed rule makes clear the obligation of facilities to post their Performance Score Certificates in a prominent location, and proposes that facilities display an English and Spanish version (both of which would be provided by CMS). Because communicating with patients is a key element of high-quality care, CMS proposes that this requirement be adopted as quickly as possible, in PY 2014.

CMS is also requesting comments on topics for future measure development, including:

• Standard Mortality Ratio;
• Standard Hospitalization Ratio—Admissions;
• 30-day readmissions;
• Issues pertaining to population/community health ,
• Efficiency/cost of care concerns;
• Health-related quality of life;
• Access to care; and
• Blood transfusion.

The proposed rule will appear in the July 11, 2012, Federal Register. CMS will accept comments on the proposed rule until Aug. 31, 2012, and will respond to comments in the final ESRD PPS rule for CY 2013 to be issued by Nov. 1, 2012.

For more information about the proposed rule, please see:

http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1

For more information about the ESRD PPS and QIP, please see:

https://www.cms.gov/Center/Special-Topic/End-Stage-Renal-Disease-ESRD-Center.html

APPENDIX

ESRD QIP PY 2015 Proposed Measures