Finalizing performance standards and scoring methodology for the Quality Improvement Program (QIP), the Centers for Medicare and Medicaid Services (CMS) issued a QIP Final Rule on December 29, 2010. CMS will implement the QIP—the first-ever mandatory pay-for-performance program within CMS—on January 1, 2012. The second major change to the Medicare ESRD program, CMS will institute the QIP exactly one year after implementing the new bundled Prospective Payment System (PPS) last month.
CMS sought public comment on a QIP Proposed Rule during the summer of 2010. ASN formed a Task Force that analyzed and provided feedback on this initial proposal composed of experts and ASN Advisory Group members. In the recently released QIP Final Rule, CMS addressed several of ASN’s key concerns and suggestions. Chief among these is the establishment of a monitoring system—a direct response to ASN’s advocacy—as well as an agreement to work with the ESRD community through a formal rule making process should CMS pursue any substantive changes to the QIP, including adoption of new measures, weights, or performance standards.
Quality measures
The three quality measures against which facilities will be measured during the first year of the QIP were finalized in the ESRD PPS Final Rule, which CMS also released in July, 2010 (Table 1). The final QIP rule reiterated this decision, but also noted that CMS anticipates replacing the average urea reduction ratio (URR) measure with a measure of Kt/V in the future. Furthermore, CMS states that it is in the process of developing “to the extent feasible” other measures that could be applied to all modalities including patient satisfaction, iron management, bone and mineral metabolism, vascular access, and fluid weight management.
Performance standards
CMS finalized its proposal to compare facilities’ data during the performance period to the lesser (more lenient) of the two following standards:
the facilities’ own performance on each measure during 2007, or
the national performance rates of all dialysis providers, calculated from 2008 data (Table 2)
CMS also finalized its proposal to establish the “performance period” as the entire calendar year of 2010—meaning that the payment reductions providers see beginning January 1, 2012, will be based on their performance in 2010. CMS indicated it will use the year 2011 to analyze 2010 data, determine which facilities met the performance standards, and allow providers time to review their performance scores before applying payment reductions during the “consequence period,” January 2012. (Figure 1).
Timeline of performance and consequence periods
Citation: Kidney News 3, 2
Performance scores and payment reductions
CMS made no changes to the scoring methodology it laid out in the QIP proposed rule. It will assign 10 points to each of the three quality measures, with facilities that meet or exceed performance standards earning a total of 30 points. For every percentage point a facility falls below one of the three standards, CMS will subtract up two points (in increments of 0.5 points) from the 30 possible total.
Additionally, CMS will weight the “hemoglobin <10 g/dL” measure as 50 percent of the total performance score. It notes that this approach establishes a disincentive for providers to undertreat patients for anemia. This is important in light of the new ESRD bundled payment system, under which administration of the drugs that treat anemia—erythropoeisis stimulating agents (ESAs)—is now a cost center rather than a source of profit for dialysis facilities. The remaining 50 percent of the total performance score will be divided equally between the two other measures. CMS noted that it will reevaluate this methodology as it adopts new quality measures in the future.
Public reporting
Under the QIP, every dialysis facility will be required to publicly post a certificate displaying data related to all three quality measures, as well as comparative data showing how well the data compare to national performance rates. This information will also be publicly available via CMS’ Dialysis Facility Compare website.
New monitoring plan
Along with other commentators, ASN emphasized that “careful monitoring in as close to real-time as possible will be crucial to the success of the QIP by minimizing adverse unintended consequences, including compromises in access to care” in its comments to CMS regarding the proposed rule. Responding directly to this concern, CMS stated in the final rule that it will “launch an ESRD services monitoring program to identify changes in beneficiary access to, and the quality of care, following the implementation of the ESRD PPS in 2011 and the QIP in 2012.”
CMS announced it will also undertake a long-term evaluation, examining relationships between ESRD and QIP policies and patient outcomes for vulnerable subpopulations. While the final rule does not provide extensive detail on monitoring or evaluation activities, it notes that CMS will utilize CROWN-Web, claims data, patient activity reports, and other quantitative and qualitative sources.
The ASN Public Policy Board and policy staff will continue to work closely with CMS to address any remaining concerns regarding the QIP leading up to its implementation, as well as to offer guidance as CMS refines plans for monitoring and evaluation activities. To read the complete QIP final rule and access other ESRD bundling-related resources, please visit www.asn-online.org/policy_and_public_affairs..
