The clouds are starting to clear on the Dialysis Facility Compare star rating system. There is still plenty of work needed to make this both a value to patients and satisfy dialysis providers, but some common ground may be emerging.

The rating system debuted on Jan. 15 against a hailstorm of criticism from the renal community: the methodology was poorly developed, the stars were unfairly distributed, and CMS wasn’t making it clear to patients and caregivers—the very groups it intended to help—how to interpret the ratings. This was not about giving a restaurant two stars for serving a cold meal, or a hotel room that was dirty. The quality of the dialysis process is measured by complex formulas, drug dosing, and other measures. The evaluations are objective, not subjective.

On Oct. 7, CMS held a National Provider Call to review what it had learned in the last 10 months about its rating system, including conclusions from a report developed by a technical expert panel that met in April to discuss ways to make it better. On Oct. 8, CMS released its yearly “refresh” of the ratings for the more than 5,000 dialysis facilities across the country.

During the provider call, the agency made it clear that it had no formal recommendations on changes to the dialysis rating system; it expected to meet with the expert panel again before the end of the year. But certainly one of the most controversial pieces is the methodology for determining the ratings. While the panel endorsed the methodology to develop the dialysis star rating system based on CMS’ objectives, it doesn’t mean the methodology will stay.

“The question was whether what CMS intended to do with the star ratings was the right thing to do with the star ratings,” said Joel Andress, PhD, Measure Development Lead for ESRD in the agency’s Division of Chronic and Post-Acute Care.

Figure out what dialysis patients really want to know
The star rating system in fact uses nine quality measures—most borrowed from the ESRD Quality Incentive Program—to measure performance. But do they reflect what dialysis patients what to know when they evaluate the quality of care being delivered? “They want something beyond clinical information and lab values,” said CMS health insurance specialist Elena Balovlenkov.

She said measuring the number of injuries and falls, evaluating staff adequacy (patient-staff ratios), performance, and training, assessing patient grievances and how they are handled, and whether clinics are promoting all modality choices equally are important measures for patients—even knowing how often patients cramp during dialysis.

To determine whether quality measures addressing these questions should be developed, CMS is creating a formalized review process. Like those used for the QIP, these measures will be vetted by the renal community and the National Quality Forum before implementation.

“We want the measures to impact improvement for patients,” said Andress. The measures will be applied to the Dialysis Facility Compare before being considered for the star ratings. “Because a measure has been approved for the DFC doesn’t mean they will or should be included in the star rating,” he noted.

The measures CMS is considering adding to Dialysis Facility are:

  • Bloodstream infection in hemodialysis outpatients (NQF #1460)
  • CAHPS (Consumer Assessment of Healthcare Providers) In-Center Hemodialysis Survey (NQF #0258)
  • Ultrafiltration rate greater than 13 ml/kg/hr
  • Pediatric peritoneal dialysis adequacy: Achievement of target Kt/V

Dialysis providers and patients have until Dec. 4 to submit other measures; new measures selected will be announced Jan. 15, 2016. A preview period will take place between July 15-Aug. 15, 2016, and new measures will be posted on Dialysis Facility Compare by mid-October 2016.

Comments should be sent to UM-KECC at on these measures and recommendations for other measures.

Dialysis industry reaction

While we welcome CMS’ focus on making recent data available, we continue to believe that the Dialysis Five Star program falls short of addressing key concerns identified by patient advocates, physicians, and others in the kidney care community,” said Dr. Edward R. Jones, chair of Kidney Care Partners. “We believe the program can and should be improved by:

  1.  Establishing a facility rating system, rather than a ranking system, that clearly communicates important and meaningful differences in quality between and among dialysis providers.
  2.   Creating consistency in CMS’ approach to the various Star Programs.  
  3.   Using quality accountability measures that evaluate care and outcomes that are within the control of the provider being evaluated.”

Moving forward with the dialysis star ratings

CMS has embraced the star rating system across many Medicare-reimbursed health care entities: nursing homes, hospitals, home health agencies, and the ESRD Program. CMS is taking a step forward by opening this process up and targeting the information that is of most value to patients.

The slide presentation from the Oct. 7 National Provider Call is available on the CMS site.