Updating the End-Stage Renal Disease Quality Improvement Program
Overview: On October 31, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates 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 January 1, 2015. This rule introduces new quality and performance measures to improve the quality of care by outpatient dialysis facilities treating patients with ESRD, and implements the Affordable Care Act provision to bring more competitive bidding for durable medical equipment.
The ESRD and DME final rule is one of several rules for calendar year 2015 that reflect a broader Administration-wide strategy to deliver better care at lower cost by finding better ways to deliver care, pay providers, and use information. Provisions in these rules are helping to move our health-care system to one that values quality over quantity and focuses on reforms such as measuring for better health outcomes, focusing on disease prevention, reintegrating patients back into the community, helping manage and improve chronic diseases, and fostering a more-efficient and coordinated health care system.
The ESRD rule also makes changes to the ESRD Quality Incentive Program (QIP), including for payment year (PY) 2017 and PY 2018, under which payment incentives are applied to dialysis facilities to improve the quality of dialysis care. Under the ESRD QIP, facilities that do not achieve a minimum total performance score with respect to quality measures established in regulation receive a reduction in their payment rates under the ESRD PPS. This rule also addresses issues related to the coverage and payment of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).
This Fact Sheet addresses the policies CMS is finalizing for the ESRD QIP, including for CYs 2017 and 2018. A separate fact sheet addressing the payment provisions of the ESRD PPS and related DME provisions for CY 2015 can be found here: http://www.cms.gov/Newsroom/Newsroom-Center.html.
ESRD QIP BACKGROUND: Section 153(c) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) amended the Social Security Act to require CMS to establish an ESRD QIP that selects measures, establishes performance standards, specifies a performance period for each PY, assesses the total performance of each facility, applies an appropriate payment reduction to each facility that does not meet a minimum total performance score, and publicly reporting the results. The ESRD QIP is intended to promote high-quality care by dialysis facilities treating patients with ESRD. This program changes the way CMS pays for the treatment of ESRD patients by linking a portion of payment directly to facilities’ performance on quality measures. The ESRD QIP will reduce payments by up to 2 percent to ESRD facilities that do not meet or exceed a certain total performance score.
QUALITY CHANGES TO THE ESRD QIP:
CHANGES TO THE PY 2017 ESRD QIP: The PY 2017 ESRD QIP measure set contains eight clinical measures and three reporting measures encompassing anemia management, dialysis adequacy, vascular access type, patient experience of care, infections, hospital readmissions, and mineral metabolism management.
Clinical Measures: Five of the PY 2017 clinical measures are captured in two clinical measure “topics” or categories (Kt/V Dialysis Adequacy and Vascular Access Type). The Standardized Readmission Ratio (SRR) measure is new. CMS is not making any changes to the Hypercalcemia and National Healthcare Safety Network (NHSN) Bloodstream Infection in Hemodialysis Outpatients measures, or to the measures in the Vascular Access Type measure topic. For the adult and pediatric hemodialysis adequacy measures, patients must be treated at least seven times in a month to be eligible for the measures in that month; otherwise, the Kt/V Dialysis Adequacy measure topic remains the same as in PY 2016. The rule also removes the Hemoglobin Greater than 12 g/dL clinical measure because the measure is “topped out.”
Reporting Measures: The three reporting measures include the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS), Anemia Management, and Mineral Metabolism. CMS is not making any changes to the specifications for the Anemia Management and Mineral Metabolism reporting measures, but the case minimums for the Anemia Management and Mineral Metabolism measures have been changed to 11; otherwise, CMS it is not changing the way the three reporting measures are scored. Additionally, facilities will no longer have the option to attest that they did not meet the case minimum to avoid being scored on the reporting measures. The eligibility requirements for the ICH CAHPS reporting measure have also been changed slightly to take more account of the number of patients a facility treats in the year before the performance period.
CHANGES TO THE PY 2018 ESRD QIP: The PY 2018 ESRD QIP measure set contains eleven clinical measures and five reporting measures encompassing anemia management, dialysis adequacy, vascular access type, patient experience of care, infections, mineral metabolism management, safety, pain management, depression management, and hospital readmissions. This represents an evolution of the program to encompass more quality-of-life issues.
Clinical Measures: In an effort to align the ESRD QIP with other Value-Based Purchasing (VBP) and quality reporting initiatives, CMS will organize the clinical measures into a Clinical Measure Domain, with component subdomains tracking to the CMS Quality Strategy.
- The Safety subdomain, accounting for 20% of the Clinical Measure Domain score, includes the NHSN Bloodstream Infection in Hemodialysis Outpatients measure.
- The Patient and Family Engagement/Care Coordination subdomain, accounting for 30% of the Clinical Measure Domain score, includes the ICH CAHPS measure and the SRR measure.
- The Clinical Care subdomain, accounting for 50% of the Clinical Measure Domain score, includes the Standard Transfusion Ratio (STrR) measure, the Kt/V Dialysis Adequacy measure topic, the Vascular Access Type measure topic, and the Hypercalcemia measure.
New clinical measures for PY 2018 include ICH CAHPS (converted from a previous reporting measure), STrR, and Pediatric Peritoneal Dialysis (part of the Kt/V Dialysis Adequacy measure topic).
Reporting Measures: The rule adopts five reporting measures. CMS continues to use the Anemia Management reporting measure, but revises the Mineral Metabolism measure revised to allow facilities to submit serum and plasma phosphorus data. CMS also adopts three new reporting measures: Pain Assessment and Follow-Up, Clinical Depression Screening and Follow-Up, and NHSN Healthcare Personnel Influenza Vaccination.
Measure Scoring: Under the rule, the clinical measure subdomain scores will be weighted according to the proportions identified earlier, then added to make up 90% of the Total Performance Score. Reporting measure scores will be weighted equally to make up the remaining 10% of the Total Performance Score.
Additional ESRD QIP COMPONENTS: The rule also establishes when a measure should be removed or replaced due to being “topped out,” the continuation of CMS’s data validation pilot program, the beginning of a CMS data validation study of data used for the NHSN Bloodstream Infection in Hemodialysis Outpatients measure, and exceptions to ESRD QIP compliance as a result of “extraordinary circumstances.”
The final rule will appear in the November 6, 2014 Federal Register and can be downloaded from the Federal Register at: http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1.