CMS dialysis clinic ratings won't help patients, critics say

Dialysis patient Roger Anderson, 68, a retired welder from Black River Falls, Wis., had to drive more than 50 miles three times a week for six months to get to his life-or-death dialysis treatments.

Those logistics became a major challenge five years ago when his kidneys failed just after he had bypass surgery. Family members often stepped in to drive him on the hourlong trek. Other times, he relied on volunteers.

So he was relieved when a spot opened up at a nearby facility and his drive was reduced to two blocks. And fortunately for Anderson, both locations were part of La Crosse, Wis.-based Gundersen Health System, whose six end-stage renal disease facilities all received five stars, the highest possible designation on a new CMS rating system.

Anderson wasn't familiar with the CMS' newly posted ratings, but now that he knows, he said they might have made a difference if his local facility was poorly rated. One star means “there's questions about what kind of service they give,” he said. “I could possibly see switching out of concern.”

The ultimate test of the star ratings, which became public Jan. 22, will be the response from patients like Anderson. Already, critics say the system is too complicated for the average consumer because of how ratings are assigned. And in areas with few choices of facilities, they may be meaningless since consumers have no easily accessible alternatives.

The stars, applied to 5,580 U.S. kidney-care centers, are meant to help patients determine quality of care. But dialysis groups say the ratings, which are based on a bell curve, do not accurately reflect the quality of care. Even centers achieving five stars have been reluctant to celebrate the results.

“We're not out there shouting it from the rooftops,” said Bridget Pfaff, administrative director for infection control, nephrology and renal care at Gundersen. The time and physical demands of treatment often require patients to choose whichever is closest. “I'm not certain a star rating is really going to impact their choice. In many communities, there is not much choice.”

There are about 450,000 patients on hemodialysis and peritoneal dialysis in the U.S., according to the U.S. Renal Data System. In 2012, Medicare spent about $58 billion on patients with chronic kidney disease. As part of a broader initiative to boost transparency and help beneficiaries compare quality, the CMS rolled out the ratings to the Dialysis Facility Compare website.

The CMS looks at nine publicly reported quality measures—such as standardized ratios for transfusions, mortality and hospitalizations. They also reflect percentages for KtV values, which show whether enough waste was removed from the patient's blood during dialysis, and how many adult dialysis patients have high calcium levels.

The ratings are based on a tiered system in which those in the top and bottom deciles received five stars (“much above average quality) or one star (“much below average quality”), respectively. The second tier, representing 20% of clinics, received four stars; the middle tier, for the next 40%, got three stars; and the next 20% got two stars.

Kidney-care groups lashed out, saying the bell curve distorts actual performance. Regions with the most one-star ratings included the Florida network; the network servicing Indiana, Kentucky and Ohio; and the network for the District of Columbia, Maryland, Virginia and West Virginia.

“It's not helpful to consumers if you can't find a differentiation of facilities within a reasonable distance from where you live,” said Jackson Williams, director of government affairs for the not-for profit Dialysis Patient Citizens. “The last thing you want to do is discourage people from complying, or to create a lack of confidence in their clinicians' advice,” he said.

The CMS told Modern Healthcare that it has updated language on the Dialysis Facility Compare website to note that a “one- or two-star rating does not mean that you will receive poor care.” It simply indicates that measured outcomes are below average compared to other facilities. There are many factors patients should weigh when making a selection, the CMS said.

But generally, consumers interpret one star as bad and five stars as good, and patients may not sift through the CMS disclaimers. “The whole point of using a star rating is that people have an understanding of what it means,” Williams said. “When you depart from that, it becomes complicated.”

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