The Medicare Payment Advisory Commission suggested in a four-page letter to CMS this week that the performance of dialysis providers involved in the renal-specific Accountable Care Organization demonstration should be judged not only on standard quality measures but on dialysis patient satisfaction with the care delivered as well.

MedPAC commissioner Glenn M. Hackbarth, JD, also suggested in the May 10 letter to Tim Love, Acting Deputy Director for Operations at the Center for Medicare and Medicaid Innovation Centers for Medicare and Medicaid Services, that cost incurred by CMS for non-emergency transports of patients to and from dialysis clinics not be included in calculating the baseline cost for patients before the demonstration begins. The agency said the transport business has been under investigation numerous times for fraudulent charges to Medicare. “In setting the historical spending baseline, CMS should exclude some or all of the expenditures for
non-emergency ambulance use by dialysis beneficiaries, particularly in areas that have high per capita expenditures (e.g., greater than the 75th percentile). This comment is based on the commission’s finding that nonemergency dialysis-related transports appear to be excessive in some states and potentially fraudulent.”
MedPAC said ambulance transports to and from dialysis facilities accounted for nearly $700 million in Medicare spending in 2011; nearly all (97%) of these transports were nonemergency transports.

Measuring performance should include patient satisfaction
CMS has yet to announce the quality measures that will be used to evaluate dialysis provider performance during the ACO demonstration, known as the Comprehensive ESRD Care model. Meeting those quality measures will determine how members of the ESRD Seamless Care Organizations that contract with CMS to take on the risk of patient care will share in the savings at the end of each performance year.

MedPAC recommended in its letter that CMS use a focused set of quality indicators “that reflect the outcomes ESCOs are designed to achieve: keeping the population healthy, better care coordination, and better patient experience.” Those key outcome measures specific to dialysis patients include mortality, hospital admission, hospital re-admission, home dialysis use, and access to kidney transplantation.

But CMS should also include patient experience measures, though subjective by nature, to measure ESCO performance because “they capture an important patient-centered dimension of quality not available elsewhere,” wrote MedPAC. “CMS should give greater weight to the domains and measures associated with outcomes and patient experience over process measures…Outcome measures provide an integrated assessment of quality because they reflect the result of multiple
care processes provided by all health care providers involved in the patient’s care.”

For a full copy of the letter, click here.