January begins the third year of the ESRD Program serving as an incubator for Medicare’s efforts to tie payment policy with clinical performance. While other CMS-directed efforts reward physicians for changing their approach to documenting care, such as use of electronic health records, or share savings in accountable care organizations, the ESRD Quality Incentive Program links a portion of payment––up to 2%––directly to dialysis facilities’ performance on quality care measures. There is no reward per se or shared savings; the ESRD QIP’s incentive is to keep what you have, or lose payment if you don’t perform. It’s the carrot and the stick, in a budget-neutral sort of way.

In 2012, most dialysis clinics did well; only 10% saw penalties based on their performance. That is down from 30% the year before. CMS will assess how dialysis clinics did in 2013 in the early part of next year.

CMS says the QIP “promotes high-quality services” and is designed to “incentivize better clinical outcomes.” But there is no mechanism in the QIP to measure whether outcomes have improved as a direct result of the program. On more than one occasion, we have heard nephrology leaders raise the question about whether the QIP measures have made a change in dialysis care. But a punitive system, based on a performance score tied to penalties, may not create the environment needed to promote better outcomes.

(CMS makes only minor changes in final ESRD QIP rule)
Policy and quality improvement
Back in 2004, then CMS administrator Thomas Scully changed the rules about the monthly capitated payment for nephrologists. Instead of making a monthly payment based on overall patient care, Scully insisted that nephrologists get paid by the visit, for up to four visits a month.  Exceptions were made to allow advanced practice nurses or physicians assistants to do up to three of those visits. Scully’s point was: We aren’t going to pay you unless you see the patient.

It’s a fine approach; there should be a sense of due diligence and reporting, particularly with a taxpayer-funded entitlement. But Scully and CMS seemed to have little interest in the outcome of the new policy. Did it improve patient care? Were patients hospitalized less? Were there more opportunities for preventive care when more physician/nurse visits led to earlier detection of other medical issues? Were patients happy with the more frequent visits?

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

It’s not clear, because CMS didn’t track those issues. But Mentari et al. examined this question in 2005, a year after the policy took affect. 1 They looked at visits and outcomes for 2,043 patients at 12 hemodialysis facilities in northeast Ohio for 12 months before and 7 months after the reimbursement change.

The change in payment policy certainly impacted behavior. For patients seen before and after the reimbursement change for at least six months, the number of visits per patient-month increased from 1.52 before to 3.14 after. The percentage of patients with no nephrologist visits per patient-month decreased from 16.6% before to 4.6% after. So clearly the new rule led to nephrologists dealing with more windshield time and chasing the new code.

However, the authors noted, “there were no clinically important changes in Kt/V, albumin level, hemoglobin level, phosphorus level, calcium level, hemodialysis catheter use, ultrafiltration volume, shortened or skipped treatments, hospital admissions, hospitalization days, or health-related quality of life, including patient satisfaction” in the patient group. Despite a marked increase in visits between patients and nephrologists, “there was no clinically important impact on parameters related to quality of care or health-related quality of life.”

What’s important?
Some argue that the QIP is built on the same chassis. In comments to CMS about the proposed rule, providers raised objections to certain measures––as they do each year. But there was a persistent request that CMS invite the dialysis community to the table to empower the measures and make them useful. CMS uses Technical Expert Panels to help lay the groundwork for new clinical measures, and members of the renal community do serve on those panels. But providers complain that transparency after the TEPs’ review and through final development of the measures is limited.

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Is renal community involvement in performance measures allowing the fox to guard the hen house? Perhaps. But ultimately, improving patient outcomes in a program where mortality remains high and catheters don’t seem to go away should be the priority for both payer and providers. Finding success requires a partnership.

The renal community is growing weary of being the guinea pig for “quality improvement” projects where they have limited influence on the rules. The low number of applicants to CMS’s Comprehensive ESRD Initiative––the renal –specific accountable care organization––that was supposed to begin in January sent a message to the agency that the details of these programs need to be formulated or at least reviewed by the renal community before implementation. Wisely, CMS has decided to regroup on the demonstration and sit down with providers to make sure the rules can fit both large and small providers, and there is enough financial incentive for those making the investments and taking on the risk. That can increase the likelihood of success.

1. Mentari EK, DeOreo PB, O’Connor AS, Love TE, Ricanati ES, Sehgal AR. Changes in Medicare reimbursement and patient-nephrologist visits, quality of care, and health-related quality of life, Am J Kidney Dis. 2005 Oct;46(4):621-7.