Following are the comments prepared by the American Nephrology Nurses Association in response to the proposed rule for the Quality Incentive Program for 2014.

ANNA is concerned that any reduction in reimbursement rates—particularly the drastic 12% reduction contained in the proposed rule—will result in cuts in both the numbers of registered nurses and the number of direct care staff available for care delivery.  At the same time, CMS is proposing to implement new and revised measures as a part of the Quality Incentive Program (QIP).  Already many nurses are overly burdened by multiple reporting obligations and often are unable to focus needed attention on direct patient care.  ANNA is concerned that the proposed cuts in reimbursement coupled with the increased reporting requirements will prove unworkable in many real-world patient settings. 

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While we recognize that measures in defined areas are required by the statute (e.g., anemia and dialysis adequacy), we would encourage CMS to examine different quality measures for those areas and others, which have more effect on patient outcomes.  For example, once an appropriate fluid management measure has been developed, we would encourage CMS to include it in the QIP as a measure for treatment adequacy and retire the existing Adult HD Kt/V measure, which is nearing “topped out” status with a performance standard of 93.6%.

Hypercalcemia
ANNA does not support the adoption of a clinical measure for hypercalcemia.  ANNA is concerned that focusing solely on hypercalcemia fails to also take into account the monitoring of phosphorous and intact parathyroid hormone (iPTH) levels as recommended by the Clinical Practice Guidelines for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease – Mineral and Bone Disorder (CKD-MBD) developed by the Kidney Disease Improving Global Outcomes (KDIGO) Initiative.  ANNA agrees with the importance of monitoring bone and mineral metabolism, however calcium, as a stand-alone measure, does not provide an accurate picture of this aspect of care. 

Use of iron therapy for pediatric patients reporting measure
CMS proposes to include NQF-endorsed measure #1433:  Use of Iron Therapy for Pediatric Patients as part of the proposed anemia management clinical measure.  ANNA has several concerns about the inclusion of this measure.  First, most of the pediatric facilities in the United States are hospital-based and do not subscribe to a system for batch data entry into CROWNWeb.  In fact, only three pediatric programs subscribe to the National Renal Administrator’s Association Health Information Exchange.  Manually gathering and entering seven data elements per patient per quarter for this measure is a significant burden, particularly since one of these is elements includes the dose of oral iron, which may not be as well documented as the doses may be obtained over-the-counter.  Additionally, there is no specification of the age/size of the child to determine if all seven points of data are required for even the smallest/youngest patients. 

NHSN bloodstream infection in hemodialysis outpatients clinical measure
ANNA believes it is important for patients to be aware of a facility’s potential bloodstream infection rates.  However, we are concerned the measure as currently proposed fails to provide facilities with a baseline upon which performance will be measured.  Therefore, rather than requiring this measure as a clinical measure, ANNA urges CMS to consider including this requirement as a reporting measure and collect the baseline data.  Collecting the baseline data prior to converting this reporting measure to a clinical measure allows for greater transparency with the dialysis community by providing achievement thresholds, performance standards, and benchmarks as a part of the rule proposing this as a clinical measure. 

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Comorbidity reporting measure
ANNA appreciates that CMS is attempting to obtain information to provide better data for the development of appropriate case-mix adjustments.  However, we are concerned that the measure as currently proposed by CMS is overly burdensome.  The proposed measure would require facilities to annually report on the 24 co-morbidities of each patient.  While this data is currently collected, it is only entered into any CMS accessed system at the time of each patient’s admission.  Some of the requested data may be readily available in the patient’s record (e.g., whether the patient has had an amputation or is an insulin-dependent diabetic) while other data (e.g., alcohol dependence or whether the patient needs assistance with daily activities) may not be readily available in the patient’s record.  In order to accurately capture data to report on the 24 co-morbidities as CMS proposes, facilities will need adequate time to update their data collection processes to add questions to the tools used for admission assessment and annual reviews. 

Even if the requested information were readily available in patient charts, a nurse would have to review each individual patient chart, locate the information, and manually process the information.  Such a task would be incredibly burdensome, particularly at a time when CMS proposes to significantly reduce the facilities’ reimbursement rates.  In light of the proposed reductions, ANNA urges CMS to refrain from imposing this additional data collection burden at this time.

Other measures under development
ANNA also encourages CMS to consider nurse-sensitive outcome measures.  Currently ANNA has created a task force to identify and develop measures which demonstrate the value of nursing care in improving patient outcomes.   

Economic analyses
ANNA believes the proposed add-on payment for self-dialysis and home dialysis training is insufficient to adequately reimburse facilities for the amount of RN time required to adequately train patients.

In addition, we are concerned the systems issues related to the CROWNWeb program impose an additional burden on facilities and nurses (to whom the burden of collecting and entering the data into CROWNWeb often falls).  As CMS estimates the economic impact of the various QIP measures, it should include a more realistic analysis of the time required to interface with the CROWNWeb system, not simply the amount of time it would take to interface with the program absent any systems issues.  Specifically, one facility in Minnesota hired a full time data entry person in June of 2013 to help the current data entry person cut down on 20 – 30 hours of overtime every pay period for the past twelve pay periods.  The burden to smaller dialysis organizations is high where they have limited resources and funding to handle this added responsibility.  Until the CROWNWeb program achieves routine optimal performance, we would encourage CMS to consider whether the addition of new measures is appropriate or whether such additional data burdens would overtax an already stressed system.