Fact Sheets
QUALITY INCENTIVE PROGRAM PROVISIONS INCLUDED IN ESRD PROSPECTIVE PAYMENT PROPOSED RULE
QUALITY INCENTIVE PROGRAM PROVISIONS INCLUDED IN ESRD PROSPECTIVE PAYMENT PROPOSED RULE
OVERVIEW: The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires the Centers for Medicare & Medicaid Services (CMS) to develop and implement by January 2011, a fully bundled prospective payment system (PPS) for dialysis services furnished to Medicare beneficiaries who are diagnosed with end-stage renal disease (ESRD).
MIPPA further requires CMS to create a quality improvement program (QIP) that would help ensure that ESRD facilities furnish high quality care to their patients. The QIP would have payment consequences beginning for services furnished on or after January 1, 2012.
The new payment system would institute financial incentives that tie payment to improving dialysis quality and outcomes. CMS expects the new system would result in both better care and reduced cost for beneficiaries and the program.
BACKGROUND: Section 153(c) of MIPPA requires CMS to develop a Quality Incentive Program (QIP) to promote improved patient outcomes by, for the first time, tying a facility’s Medicare payment rate to how well the facility performs on quality of care measures. Facilities that do not meet or exceed minimum performance standards in a period determined by the HHS secretary will receive payment reductions of up to two percent for a specified year.
The law also requires CMS to select measures and develop performance standards for health care categories such as anemia management and dialysis adequacy. In choosing measures, MIPPA instructs CMS to consider the availability of data to calculate such measures. In addition, as part of this program, CMS must develop procedures for making the QIP information public, after giving providers and facilities an opportunity to review the information that is to be released.
The program will be the first time in which CMS would directly link payments to quality of care. In the past, CMS has used a pay-for-reporting framework for inpatient and outpatient hospital services, and physician services.
This proposed rule for establishing an ESRD PPS outlines how CMS intends to proceed with the QIP and proposes the measures that will be included in the QIP. Performance standards and other implementation issues will be addressed in a separate proposed rule.
QIP PROPOSALS IN THE ESRD PPS PROPOSED RULE: The ESRD PPS proposed rule proposes the following three specific measures that will apply to the initial performance period of the QIP:
Hemodialysis Adequacy: Achieved urea reduction ratio (URR) of 65 percent or more; and Anemia Management: Controlled anemia, as shown in two measures:
* the percentage of patients at a facility whose hemoglobin levels were less than 10 grams per deciliter (g/dL), and
* the percentage of patients at a facility whose hemoglobin levels were greater than 12 g/dL.
The proposed measures were chosen because dialysis facilities have used them since 2001. These measures are currently collected from Medicare dialysis facility claims so there is no need for separate reporting. Finally, CMS already has data on these measures which it can use to develop and test models for the operation of the QIP.
As required by law, CMS plans to establish performance standards for each of the measures and facilities would be scored based on their adherence to the measures. Providers and facilities that do not meet or exceed the total performance score during a performance period would see up to a two percent reduction from their payment rates in the succeeding year.
CMS will accept comments on this conceptual QIP model in the ESRD PPS proposed rule through November and will issue a separate proposed rule based on consideration of the comments received at a future date.
For more information, please see: http://www.cms.hhs.gov/ESRDPayment/
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