When the Centers for Medicare & Medicaid Services looks at the cost of the End-Stage Renal Disease Program—$34.3 billion in 2011—it recognizes that hospitalizations are one of its most costly line items. In 2010, 38% of the total ESRD Program expenditures went to inpatient costs. So quality measures that help track the cause of hospitalizations, and ultimately tie payment to reducing admissions, would be good for the Medicare program. But dialysis providers were not enthusiastic about including such a measure in the payment year 2016 ESRD Quality Incentive Program.

(QIP tracks performance, but are the measures improving patient care?)

When CMS prepares proposed changes each year to the upcoming ESRD QIP, it asks the renal community their opinion about future measures. Quality measures adapted by CMS for the ESRD QIP can be approved or be based on measures approved by the National Quality Forum (NQF), or can be approved by an organization selected by the Secretary of Health and Human Services. All proposed measures go through a vetting process with input from organized Technical Expert Panels and input from the renal community during the proposed rule process. 

In the FY 2016 proposed rule released in July 2013, CMS asked for comments on adding three new clinical measures (Patient Informed Consent for Anemia Treatment, Hypercalcemia, and NHSN Bloodstream Infection in Hemodialysis Outpatients) and two new reporting measures (recording use of iron therapy in pediatric dialysis patients, and tracking comorbidities). “We believe that, collectively, these measures will continue to promote improvement in dialysis care in the PY 2016 ESRD QIP and in future payment years,” CMS wrote.

Tracking hospitalizations
CMS made it clear that the comorbidities reporting measure would help the agency track hospitalizations and get a better understanding of the severity of illness among dialysis patients, and perhaps anticipate the need for hospitalizations—and help control some of those Medicare costs. But providers were wary about the proposed measure—enough so that CMS shelved plans to adopted it for now. Here is their explanation of the measure, and their rationale, based on comments from the renal community, to delay inclusion in the PY 2016 QIP.

(CMS responds to queries about new measures in ESRD QIP rule)

'Long interest' in SMR and SHR measures
CMS notes that the NQF has already endorsed a clinical measure for Dialysis Facility Risk-Adjusted Standardized Mortality Ratio (#0369) and a clinical measure for Standardized Hospitalization Ratio for Admissions (#1463).

“We have long been interested in adding a Standardized Mortality Ratio (SMR) measure and a Standardized Hospitalization Ratio (SHR) measure to the ESRD QIP. As articulated in the CY 2013 ESRD PPS final rule, "We believe that dialysis facilities own partial responsibility for the rate at which their patients are hospitalized, in particular when that rate is substantially higher than at other peer facilities and may not be explained by variation in the illness of patients (77 FR 67496).’ “

“Similarly, we continue to believe that the SMR may help distinguish the quality of care offered by dialysis facilities as determined by mortality, a key health care outcome used to assess quality of care in other settings, such as hospitals (77 FR 67497)."

(CROWNWeb, CMS plan forums about ESRD QIP)

The purpose of the comorbidity measure, CMS said, would be two-fold. It would offer a mechanism for collecting annual information about patient comorbidities, thereby providing a reliable source of data for CMS to develop a risk-adjustment methodology for the SHR and SMR clinical measures, should they be adopted in the future. The reporting measure will also make it possible to improve CMS’ understanding of the risk factors that contribute to morbidity and mortality in the ESRD patient population “and therefore more reliably calculate expected hospitalization and mortality rates in future payment years of the ESRD QIP.”

CMS acknowledged in its final rule the concerns providers have expressed previously that the NQF-endorsed SMR and SHR measures are not adequately risk-adjusted. That is partially due to a lack of information: the Medical Evidence Reporting Form 2728, which is typically only submitted by facilities to CMS when a new patient first begins to receive dialysis treatment, is not updated, which makes it difficult to capture information about comorbidities that develop after the initiation of dialysis treatment. “We acknowledge the concerns of commenters who stated that ‘there is currently no mechanism either for correcting or updating patient comorbidity data on CMS’ Medical Evidence Reporting Form 2728, and these comorbidities affect the calculation of the measure (76 FR 70267).”

But CMS said it could resolve that problem. “When we examine updated data on comorbidities, we will determine the appropriateness of including that data as additional risk adjustment factors for the SMR and SHR measures by considering the extent to which each CMS-1526-F 191 comorbidity may be influenced by the quality of dialysis facility care, as opposed to factors outside of a facility’s control.”

(Finding the good news in the ESRD PPS final rule)

Details of the proposed measure
For the reporting measure, CMS wanted each facility to annually update in the CROWNWeb data collection system up to 24 comorbidities, or indicate “none of the above,” for each qualifying case. “For the purposes of this measure, we proposed to define a ‘qualifying case’ as a hemodialysis or peritoneal dialysis patient being treated at the facility as of Dec. 31 of the performance period, according to admit and discharge dates entered into CROWNWeb. In fulfilling this reporting requirement, dialysis facilities would select one or more of the following comorbidities for each qualifying case.

  • Congestive heart failure
  • Diabetes, on oral medications
  • Drug dependence
  • Atherosclerotic heart disease
  • Diabetes, without medications
  • Inability to ambulate
  • Other cardiac disease
  • Diabetic retinopathy
  • Inability to transfer
  • Cerebrovascular disease
  • Chronic obstructive pulmonary disease
  • Needs assistance with daily activities
  • Peripheral vascular disease
  • Tobacco use (current smoker)
  • Institutionalization–assisted living
  • History of hypertension
  • Malignant neoplasm, cancerInstitutionalization – nursing home
  • Amputation
  • Toxic nephropathy
  • Institutionalization – other institution
  • Diabetes, currently on insulin
  • Alcohol dependence
  • Non-renal congenital abnormality
  • None of the above

If a dialysis clinic wanted to receive full points on this measure under the QIP, facilities would be required to provide the updates in CROWNWeb by Jan. 31, 2015. “While we proposed to require facilities to report a single annual update per patient, we encourage facilities to update this information more frequently in order to more closely monitor their patients’ risk factors, and to improve the quality of the data.”

Comments from the renal community
While CMS said several commenters supported the proposal to adopt the comorbidity reporting measure and the decision to collect more information before adopting the SMR and SHR measures, “many commenters did not support the proposal.” Several commenters stated that they did not think the comorbidity reporting measure was a quality measure and expressed a concern that it had never been developed nor endorsed by a consensus-based organization. Commenters also stated that CMS should either use the ESRD Conditions for Coverage requirements or should revise the Form 2728 to accomplish this data collection, rather than using the ESRD QIP for this purpose.

“As a result of the significant concerns expressed about the measure, we have decided not to finalize the measure at this time," CMS said. "We will consider whether there is a better way to update this important comorbidity information, including the suggestion to collect comorbidity data under the CfCs, in the future.”

So for now, dialysis providers will not face a QIP measure for hospitalizations. But based on the cost of inpatient care, and the need to control Medicare costs, we can expect that CMS will keep the SMR and SHR measures, already approved by the NQF, on the table.

Find all of NN&I's recent QIP coverage at NephrologyNews.com/QIP