Kidney-care providers could see their Medicare payments reduced by up to 2% in the next few years if they do not score high enough on quality measures.
The CMS on Friday proposed updates to policies and payments for end-stage renal disease, which would affect payments to more than 6,000 U.S. kidney dialysis facilities.
In recent years, the agency has focused on efforts to drive high-quality care, such as disease prevention, chronic disease management, improving outcomes and promoting efficiency.
The ESRD proposal released last week is part of that broader push. It would change how dialysis facilities are reimbursed by linking a portion of their payments directly to quality scores. It would also eventually add new metrics to the ESRD Quality Improvement Program.
There are currently 11 measures to evaluate end-stage renal disease care through the quality program. They include eight clinical measures, such as: how many patients receive the best vein access method (arteriovenous fistula) versus the least recommended (catheter), how well toxins are being filtered from the blood during dialysis; infection rates; and how well hypercalcemia is controlled. They also include three reporting measures, including patient experience, anemia and bone mineral metabolism management.
The CMS assigns a score for each measure, and those scores are later combined to create a “total performance score”—which ranges from zero to 10- for each facility. Centers that do not meet the minimum score established by a benchmark determination would be financially penalized up to 2% of its Medicare reimbursement.
It is estimated that the treatment of end-stage renal disease costs Medicare $34 billion in 2011, about 6% of all Medicare spending. Hemodialysis for end-stage renal disease costs the program about $88,000 annually per patient.
The CMS plans to add quality-of-life measures, such as pain and depression management and readmission rates in 2018. By 2019, two new measures will be adopted: one looking at seasonal flu vaccination, and ultrafiltration rates, a process for removing excess water and sodium from the body of kidney-failure patients.
Although studies have suggested that higher ultrafiltration rates in hemodialysis patients are associated with a greater risk of all-cause and cardiovascular deaths, nephrologist Dr. Alan Kliger, chief quality officer for Yale New Haven Health System, cautions against the premature use of the ultrafiltration metric.
Higher amounts of life-threatening fluids accumulate between treatments for patients who eat or drink more than recommended, and they would need ultrafiltration. “That doesn't necessarily mean that higher filtration causes more deaths,” Kliger said. “They may be dying not because we are ultrafiltering them more but because they have physiologies that make them more dangerous patients.”
That particular measure has not been endorsed by the National Quality Forum, a nonprofit that reviews and endorses quality improvement metrics. In a draft report issued in June, the NQF's Renal Standing Committee declined to recommend the metric the CMS plans to adopt and instead recommended a different one for ultrafiltration.
Dr. Frank Maddux, chief medical officer of Fresenius Medical Care, one of the two largest U.S. dialysis providers, expressed similar concerns about CMS’ use of measures that are either not endorsed or are being considered for removal by NQF.
He also raised questions about measures for standardized transfusion and hospitalizations, which he said appear to rely on baseline performance data submitted in 2013 for the 2018 payment year.
“It strikes me that those measures are not very mature,” he said. That’s a major concern since a 2% reduction is a “substantial issue all providers take seriously.”
However, even imperfect measures can work if they are valid, reliable and feasible in the evolution of the systems to capture data, Maddux said. “They become points of concentration for the organizations that are providing care."
But, he added, "If that concentration is not aligned with the state of the science, then we aren’t spending our time on those things that are most important.”