MEDICARE PROPOSES FRAMEWORK FOR THE ESRD QUALITY INCENTIVE PROGRAM
FOR PYS 2013 AND 2014
On July 1, 2011, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would update payment policies and rates for dialysis services furnished to Medicare beneficiaries that are paid under the End-Stage Renal Disease Prospective Payment System (ESRD PPS). The proposed rule also includes proposals for strengthening the Quality Incentive Program (QIP), under which payments to dialysis facilities are reduced if they do not achieve a high enough total performance score based on their performance on measures that assess the quality of dialysis care. Both the ESRD PPS and the QIP were mandated by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA).
Over the past 35 years, CMS has instituted a series of quality initiatives to improve dialysis care. The ESRD QIP builds upon and enhances CMS’ commitment to improve quality by allowing CMS for the first time to tie ESRD facility payments to their performance on measures of quality.
The QIP is designed to improve patient outcomes by establishing payment incentives for dialysis facilities to meet performance standards established by CMS. Under the ESRD QIP, for the first time, payments are tied not only to the items and services provided at a facility, but also to the quality of care beneficiaries receive at the facilities.
By law, the QIP must include measures of dialysis adequacy and anemia management. These measures were incorporated into the payment year (PY) 2012 program and low facility performance on those measures could affect payments to them beginning with January 1, 2012 services. In addition, the statute states that, to the extent feasible, the program must include measures of patient satisfaction, iron management, bone mineral metabolism, and vascular access.
The first ESRD QIP final rule was published in the Federal Register on Jan. 5, 2011. Today’s proposed rule would update the QIP measures and scoring methodologies that would affect payments to dialysis facilities in PY 2013 and PY 2014.
DETERMINING TOTAL PERFORMANCE SCORES FOR PY 2013 AND PY 2014
Similar to what it finalized for the first year of QIP, CMS is proposing to evaluate a facility’s quality of care by calculating that facility’s performance on established measures during a set performance period. This performance will be compared to standards established by CMS to generate a score. The scores for individual measures will then be combined into a total performance score that determines whether the facility will receive a payment reduction. Payments will be reduced on a sliding scale to ensure that reductions are proportionate to the degree a facility underperforms, up to a maximum of 2 percent for a year. CMS will allow facilities to review their scores for accuracy before publishing these scores on the Dialysis Facility Compare website. Facilities will also be required to display certificates containing their performance score prominently in the facility.
CMS is proposing to revise the scoring method and performance standards. By law, CMS was required to set the initial performance standard as the lesser of:
- The facility’s own performance in the year that was selected for purposes of the ESRD PPS based on lowest per patient utilization (which was CY 2007 for the PY 2012 ESRD QIP) or
- A standard based on the national performance rates in a selected period (which was CY 2008 for the PY 2012 ESRD QIP).
CMS is now proposing to continue using the “special rule” to set the performance standards for the PY 2013 QIP. Under this proposal, the performance standard with respect to a measure would be the lesser of a facility’s CY 2007 performance on the measure, or the national performance rate for the measure in CY 2009 (the most recent data available). CMS is proposing to eliminate this “special rule” for the PY 2014 program and is proposing a new scoring methodology as outlined later in this fact sheet.
PROPOSED ESRD QIP MEASURES AND SCORING FOR PY 2013
For the PY 2013 program, CMS is proposing to measure facilities’ performance on two measures:
- An anemia management measure that assesses the percentage of patients with a hemoglobin level greater than 12 g/dL (for which a lower percentage indicates better performance on the measure); and
- A hemodialysis adequacy measure which assesses the percentage of patients with a urea reduction ratio (URR) of at least 65 percent (for which a higher percentage indicates better performance on the measure).
In addition, CMS is proposing to retire the anemia management measure that assesses the percentage of patients with a hemoglobin level below 10 g/dL. CMS has proposed to retire this measure because the medical evidence does not show that targeting a hemoglobin level of at least 10 g/dL is the most appropriate treatment option for many dialysis patients. The proposal is consistent with the US Food and Drug Administration’s recent revised dosing guidelines for erythropoietin-stimulating agents (ESAs) when used to treat anemia in patients with chronic kidney disease (CKD).
To calculate the total performance score for PY 2013, CMS is proposing to weight each of these measures equally at 50 percent and to use CY 2011 as the performance period. CMS is proposing that facilities would be scored from 0 to 30 points and that payment reductions would be applied on a sliding scale. Unlike the PY 2012 QIP, in which a facility could avoid a payment reduction by scoring 26 points or higher, CMS proposes that a facility would need to earn all 30 points in order to avoid a payment reduction in PY 2013. Payment reductions for PY 2013 would range from 1.0 to 2.0 percent.
PROPOSED ESRD QIP MEASURES AND SCORING FOR PY 2014
CMS is proposing to adopt 5 clinical measures and 3 structural measures for the PY 2014 ESRD QIP. The 5 clinical measures are:
- The anemia management measure finalized for PY 2012 and proposed for PY 2013 (hemoglobin greater than 12 g/dL);
- Dialysis adequacy (as computed using the Kt/V formula);
- Type of vascular access, including use of the preferred arteriovenous fistula and reduction in catheter use;
- Vascular access infection; and
- Hospitalization rate s.
The 3 structural measures will capture (in a yes/no format) whether a facility:
- Reports dialysis infection events to the Centers for Disease Control and Prevention;
- Surveys patients to learn about their experience of care; and
- Monitors patients for abnormalities in phosphorus and calcium levels.
For the PY 2014 ESRD QIP, CMS is proposing to score facilities on both achievement and improvement on each of the 5 clinical measures. A facility’s achievement score would be determined based on where its actual performance falls in comparison to a specified national achievement threshold and a national benchmark. A facility’s improvement score would be determined based on where its actual performance falls on a scale ranging between its performance during the baseline period and the national benchmark. The proposed baseline period for four of the proposed PY 2014 measures is July 1, 2010 through June 30, 2011, and it is CY 2010 for the proposed hospitalization rate measure. The proposed performance period for all five of the proposed clinical measures is CY 2012.
For each of the five proposed clinical measures, CMS is proposing to award a range of points for the achievement score (1 to 10 points) and the improvement score (0 to 9 points) based on a facility’s performance on each measure. For each of the three proposed structural measures, CMS is proposing to award points as follows:
- For the proposed measure on the reporting of dialysis infection events, facilities could earn a score of 0 (for not being enrolled in the National Health Safety Network, which is run by the Centers for Disease Control and Prevention), 5 (enrolled and completed necessary training), or 10 points (enrolled and reported 3 consecutive months of data).
- For the proposed measure on administering the patient care experience survey during the performance period, facilities that conduct the survey would receive 10 points, while those that do not would receive 0 points.For the proposed mineral metabolism reporting measure, CMS is proposing that facilities conducting monitoring on all adult patients at least once per month would receive a full 10 points, while those that do not would receive 0 points.
CMS is proposing to base 90 percent of a facility’s total performance score on the clinical measure scores applicable to the facility (with each clinical measure weighted equally), and 10 percent of the total performance score on the combined reporting measure scores (with each reporting measure weighted equally).
CMS is proposing to reduce payments to facilities that do not meet or a minimum total performance score of 30 points. Facilities that fall below the minimum score by less than 10 points would receive a 1 percent payment reduction; 10 to 20 points below would receive a 1.5 percent payment reduction; and more than 20 points below would receive a 2.0 percent payment reduction.
CMS will accept public comments on the proposed rule through Aug. 30, 2011. CMS will review all comments and respond to them in a final rule to be issued later this year.
For more information, please see:
More information about the ESRD QIP is available on CMS’ website at http://www.cms.gov/ESRDQualityImproveInit
# # #