Nearly one in three dialysis clinics will receive a payment reduction under the new QIP. Is it the clinics, or the QIP, that need to improve?

CMS has announced the first QIP results and made the following payment reductions to dialysis facilities:
•    16.6% of dialysis facilities will receive a 0.5% reduction
•    6% will receive a 1% reduction
•    7.7% will receive a 1.5% reduction
•    0.6 % will receive a 2% reduction 

As a whole, dialysis facilities made out OK; most facilities that received reductions were penalized less than 1%. But even a small reduction in reimbursement is likely to bring about practice changes, and the gnawing question is whether these changes will be positive.

NN&I's upcoming January issue features a series of articles that review the program’s structure and look closely at how the QIP expects to improve quality. The measure that seems to concern clinics the most is the upper Hgb threshold of 12 g/dL.

In their upcoming article, "Perpetuating sub-optimal care: CMS, QIPs, and the hemoglobin myth," Stephen P. Pollak, PhD, Jonathan A. Lorch, MD, FACP , and   Victor E. Pollak, MD, FACP, FRCPE demonstrate how the measure could lead to worse patient care. The measure "reflects a flawed understanding of disease complexity, reinforced by three problematic randomized controlled trials." In their clinics, the authors have been exploring the "complex role of iron deficiency and other variables in anemia, and the merits of alternative therapeutic approaches."  Their practice-based studies have led to lower mortality and hospitalization rates, but sometimes patients have exceeded the Hgb threshold.

"We have been pioneering a new approach to anemia through a program of practice-based research, and continuous quality improvement," the authors write in NN&I. "Our databased, outcomes-oriented methods are patient, not population driven; achievement not target driven; and focused on addressing individual needs over time. The results so far include much-improved outcomes, with fewer drug inputs, than national and international norms. But the financial penalties under the QIP program give us little choice. We exceed the QIP upper threshold. Our work must stop; we must downgrade our care."

The anemia measure does not leave room for innovation or research. "The ability to innovate, to move the boundaries of knowledge forward, is essential to improve patient care, and to ensure our financial viability as a regional patient care organization," the authors wrote.

Although the QIP was enacted out of a desire to improve patient care, it could end up halting the improvements to patient care that some clinics have been working towards.

Of course, not all Hgb levels that exceed the measure do so as a result of carefully prescribed and monitored treatment methods, such as with the NN&I authors.  Is it possible to penalize clinics that offer sub-optimal care, while still leaving room for innovation and improved treatments?  Do the QIP measures have to remain one size fits all?