ESRD QIP Penalties Don't Lead to Improvements in Dialysis Center Care

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Dialysis centers hit with financial penalties under the Centers for Medicare & Medicaid Services' (CMS) mandatory End-Stage Renal Disease Quality Incentive Program (ESRD QIP) do not show subsequent improvement in quality of care, concludes a study in Annals of Internal Medicine.

The study used publicly available Medicare data on 5830 dialysis centers from 2015 to 2018. In 2017, financial penalties (based on 2015 performance) were levied on 1109 centers, representing 19.0% of the total. Regression discontinuity models were used to evaluate the association between penalization and subsequent changes in dialysis center quality, based on data from 2017 and 2018. In addition to the 0 to 100 composite metric, individual factors contributing to the total performance score were analyzed.

Penalized centers were located in ZIP Codes with a higher average percentage of non-White race residents, 36.4% versus 31.2%, and with a lower median income, $49,290 versus $51,686. Chain-affiliated centers accounted for 84.0% of penalized centers versus 93.6% of non-penalized centers. More than one-half (52.2%) of penalized centers were in the South US Census region.

For penalized centers, total performance scores did not improve in subsequent years, with changes of just 0.4 point in 2017 and 0.3 point in 2018. The findings were unchanged by adjustment for dialysis center characteristics or on analysis of centers penalized for the first time in 2017. There were also no improvements in specific components of the total performance score.

The ESRD QIP was designed to address the wide variation in quality of care provided at US outpatient dialysis centers. However, the program has not undergone independent evaluation, and its effects on quality of dialysis care remain unknown.

The study shows little or no improvement in quality of care at dialysis centers receiving financial penalties under the ESRD QIP. The findings are consistent for centers with differing characteristics and across individual quality metrics. The investigators conclude: “These data suggest that CMS may consider changes to the program design as [it continues] to experiment with ways to improve the care of patients with ESRD” [Sheetz KH, et al. Changes in dialysis center quality associated with the End-Stage Renal Disease Quality Incentive Program: An observational study with a regression discontinuity design. Ann Intern Med, published online ahead of print June 1, 2021. doi: 10.7326/M20-6662;].