Measuring Quality

Throughout 2012, the nephrology community will be focused on how Medicare’s new Quality Incentive Program (QIP) affects patient outcomes and practice patterns.

Mandated by the Medicare Improvement for Patients and Providers Act of 2008, the QIP is the only mandatory “pay-for-performance” program in Medicare. The QIP was designed to establish performance standards for dialysis facilities and to adjust payments based on meeting (or not meeting) those standards.

Speaking at Kidney Week, Jeffrey Berns, MD, FASN, described QIP as a “pay for nonperformance” program or P4nP, since facilities will receive a payment deduction of up to 2 percent if certain performance measures are not met. Reductions in years 2012 and 2013 will be based on hemoglobin measures and urea reduction ratio (URR), with several clinical and process measures being added in 2014. Reductions are made based on a complicated scoring system. Data used for reductions in 2012 and 2013 will come from claims filed in 2010 and 2011 respectively, leaving little room for actual quality improvement based on QIP.

Two of the QIP measures are already met by the majority of dialysis facilities: 96 percent have URR ratio of at least 65 percent and 84 percent keep hemoglobin less than 12 mg/dL. The fact that many facilities meet these standards begs the question of whether these measures really address a performance gap, Berns noted. The two measures also were not endorsed by the National Quality Forum, of which Berns holds a seat as the ASN representative. But they were included in the actual mandate for Congress, so by law they must be included.

Daniel Wiener, MD, assistant professor at Tufts University and member of the ASN’s Dialysis Advisory Group, noted that what is good for the majority of patients will still not benefit everyone and may even negatively affect a subpopulation of patients. As a case study, Weiner described how one of the 2014 QIP measures (use of AV fistula) may not be the best choice for everyone. For the elderly, physicians must choose carefully among arteriovenous (AV) fistula use versus catheter or AV, he said. Although targets are set at less than 100 percent to help physicians individualize therapies, Weiner said this may not be adequate to allow for adjustment.

The major components of a pay-for-performance program are operationalizing quality and designing incentives followed by communication, implementation, and evaluation, said Rajnish Mehrotra, MD, FASN, chair of the ASN Dialysis Advisory Group and associate professor at UCLA. Mehrotra applied the dimensions of quality outlined in the Institute of Medicine’s 2001 report, demonstrating that QIP is making an effort to provide higher quality care by addressing clinical effectiveness (HgB, URR), patient safety (infection reporting), and patient centeredness (patient experience survey), but has not successfully addressed timeliness, efficiency, or equity.

The incentive structure for the QIP is also off kilter, Mehrotra said, using a payment withhold instead of bonuses, and using payment periods far removed from actual performance periods.

Ultimately, many in the kidney community remain optimistic about the use of quality measures in nephrology care, but will continue to advocate in 2012 for appropriate and effective measures that are better aligned with provider care and reimbursement.

January 2012 (Vol. 4, Number 1)