Medicare's new five-star quality-rating system for dialysis facilities suggests significant disparities between the care provided by the nation's largest kidney-care companies. Far fewer Fresenius Medical Care facilities earned five- and four-star ratings than those of competitor DaVita Kidney Care.
The federal agency posted the star ratings last week as part of a broader initiative to boost transparency and help Medicare beneficiaries compare quality in healthcare settings. Kidney-care groups have been vocal about their concerns with the methodology and called the results distorted. DaVita, in a news release issued Monday, called the results “gratifying,” but also said the company shares the frustrations other kidney-care groups have with the rating program.
Fresenius and DaVita combined represent about 60% of the more than 5,500 facilities that were rated, and there were stark differences between how the companies performed, according to a Modern Healthcare analysis of the ratings posted to the CMS' Dialysis Facility Compare website.
Fresenius facilities account for nearly half of all facilities nationwide to receive just one-star, which the CMS describes as “much below average quality.” The company has 259 sites listed in that bottom rung and just 53 rated in the top tier. A total of 1,738 Fresenius facilities received ratings.
DaVita, on the other hand, had 324 facilities that earned a five-star rating, making up 57% of the ones in that category. Forty DaVita facilities, out of 1,785 rated, received the lowest score.
Overall, a total of 565 dialysis facilities were “much above average quality” and received the full five stars, while 545 were “much below average quality” and received one star. This is consistent with methodology outlined by the CMS, which noted only facilities in the top decile would receive the five stars, while those in the bottom decile would receive one. Those in the next 20% received four stars, the middle 40% got three stars and those in the next 20% were given two stars.
“The Five Star system forces some high-performing clinics into lower rankings due to its use of a bell curve ranking system versus one that is purely objective,” DaVita said in its news release. DaVita Kidney Care is the largest division of Denver-based DaVita HealthCare Partners.
Dr. Frank Maddux, Fresenius' chief medical officer, and Robert Sepucha, the company's senior vice president of corporate affairs, attributed some of the differences to a lack of standardization around the way data is gathered and reported to the CMS. Not all of its facilities had been collecting data on measures such as transfusion ratios because transfusions typically take place outside of the dialysis unit, and that skewed the results, according to Fresenius.
They also said there is no consensus on when to begin counting to determine the percentage of adult patients who had a catheter left in a vein longer than 90 days.
“You've got providers doing the activity in different ways and that has an impact on the final rating,” Sepucha said. “There's not a good one-to-one correlation.”
Fresenius has prioritized reporting on standardized mortality and hospitalization ratios, and its average scores were about the same as DaVita's those two outcomes, Modern Healthcare's analysis found. But Dr. Alan Kliger, chief quality officer for Yale New Haven Health System, says the similar performance there is not surprising.
Though they are important to track, mortality and hospitalization ratios for dialysis patients may be influenced by “scores of variables” that are beyond the provider's control, such as the severity of the patient's disease and access to care. “It's not that they are doing so great with it, it's just that they are not so terribly different from each other because the underlying factors far outweigh the things that we can manipulate and change clinically,” said Kliger. His research focuses on maintaining safety in the dialysis facilities.
On the other hand, for use of arteriovenous fistula and central venous catheters, and in more recent studies, controlling for hypercalcemia, process changes can clearly lead to improved outcomes. “I think the CMS has picked very good and reasonable measures for what we know now about the best way of delivering care and what we can do to try to improve it,” Kliger said. The star ratings, he said, help to shine a light on those measures and encourage all facilities to attend to them. “And I think that's a good thing."
The CMS generated the star ratings using nine publicly reported quality measures—such as standardized ratios for transfusions, mortality and hospitalizations—and percentages for KtV values, which show whether enough waste was removed from the patient's blood during dialysis. The ratings also reflect percentages of adult dialysis patients with high calcium levels.
When the results were posted Jan. 22, Kidney Care Partners, a coalition of patient advocates and dialysis professionals, and Dialysis Patient Citizens, a patient-led not-for-profit, issued statements reiterating their complaints that the ratings misrepresent the quality of care provided and ultimately do not “empower consumers to act on quality information in a realistic manner.”
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