Judging the value of quality measures and the quality of care in the ESRD program

While the 12% cut to the bundled payment has taken center stage in the review of the Centers for Medicare & Medicaid Services’ proposed rule for the Prospective Payment System, the planned changes to the ESRD Quality Incentive Program have also gathered some attention. NN&I is looking at how different professional organizations and patient groups evaluated the proposed ESRD QIP for 2014 and summarize their important comments. Complete comments from these organizations and others are available here.

KCP critical of measures, structure of ESRD QIP

In its comments about the proposed rule for the Quality Incentive Program for the upcoming 2014 performance year, Kidney Care Partners reiterates its request for the Centers for Medicare and Medicaid Services to include the renal community more in the development of clinical measures--if the agency wants to see a subsequent improvement in outcomes. “Although KCP continues to support the QIP generally, we remain concerned about certain aspects of the program that remain unresolved, despite our ongoing discussions with the agency about them,” they wrote.

Overall issues, the KCP said, include:

CMS should establish a consistent minimum set of exclusions that apply to all measures, including patients who die within the applicable month; those who receive fewer than seven treatments in a month; those who are receiving home dialysis therapy who miss their in-center appointments; and transient dialysis patients. Pediatric dialysis patients (unless the measure is specific for assessing patient care in this group) and transplant patients should also be excluded.
The agency should refrain from relying upon CROWNWeb until the problems that continue to plague the system are resolved.
CMS should adopt a more transparent approach by providing the data and assumptions used to calculate the rate of improvement and performance benchmarks for all measures at the time of publication of the proposed rule to allow stakeholders the opportunity to assess the impact on dialysis facilities.

More specific to the 2014/2016 proposal, KCP said measures such as the anemia management hemoglobin >12 d/gL, the adequacy of dialysis, and vascular access measures should be maintained. For the access clinical measure, however, KCP urges CMS to consider allowing access grafts to be a viable alternative to fistulas. “Reducing catheters in favor of a permanent access (ideally, an AV fistula, but in some instances a clinically appropriate graft) is arguably the most important factor in improving patient outcomes. Yet, we remain concerned that the Agency has not addressed previous comments regarding the negative clinical impact created by having fistula and catheter measures without a graft measure. By not including a graft measure, the vascular access type composite measure creates a disincentive for using this clinically appropriate access even when it is in the best interest of a patient,” KCP wrote.

More clarification is needed on proposed modifications to the specifications for the mineral metabolism and anemia management reporting measures, KCP wrote. It also recommends that CMS not adopt the patient informed consent for anemia treatment, the use of iron therapy for pediatric patients, and co-morbidity data measures. And, because of a lack of accurate data, KCP is against adoption of the hypercalcemia measure as a clinical measure––but would support it as a structural reporting measure. CMS had originally proposed the hypercalcemia clinical measure for performance year 2013, but held off based on comments from the community that data collection was inadequate. KCP also doesn’t want the agency to move the NHSN bloodstream infection measure from a structural reporting measure to a clinical measure.

NRAA suggests leniency for clinics impacted by disasters in NHSN reporting

The National Renal Administrators Association, which represents small and medium-sized providers, sided with the Kidney Care Partners on many points regarding the proposed rule for the Quality Incentive Program for 2014/2016, including comments about the vascular access measure, measuring iron use in pediatric patients, and expanding the frequency of the CAPHS survey. Other comments included:

For new measures, the NRAA suggested that the Agency consider implementing a measure related to the education of patients with chronic kidney disease as they enter ESRD. “Providing CKD patients with the appropriate education regarding prevention before they reach CKD stage 5 would delay the onset of ESRD and the need for dialysis. Further, if these transitioning patients are provided with the proper education regarding renal replacement therapies, the transition to dialysis could be smoother, with fewer complications,” the NRAA wrote in its comments. Patients should also be provided education regarding diet, access placements, support programs, rehabilitative services, and anemia and blood pressure control, they said, adding “a measure of this type should be a physician quality measure, as the physicians are responsible for providing this information to their patients prior to the patient reaching CKD Stage 5.”

The NRAA also suggested CMS consider removing restrictions on the types of services a dialysis facility can bill, opening the door to work with physicians to provide primary care, mental health, and podiatry concurrently while the patient is receiving dialysis. “Allowing providers to perform these services in a dialysis facility and bill for them would be beneficial to ESRD patients because they would not have to travel to other locations to receive necessary care,” the Association wrote.

Current measures
Similar to comments by the KCP, the NRAA said it was concerned about the agency’s proposal to require the ICH CAHPS survey for patient satisfaction given twice during the performance period beginning in payment year 2017. “Increasing the frequency of surveys can lead to survey fatigue and potentially dissatisfaction with the facility because of the redundancy of surveys,” the NRAA wrote. “This is especially true in facilities that also perform patient satisfaction surveys. Because of the frequent surveying, as well as the length of these surveys, patient response rates are low.”

The NRAA said it was also concerned that approximately one-third of the ICH CAHPS survey is about physician behavior, over which dialysis facilities have little control. “The NRAA respectfully suggests that if the Agency would like to have an impact on

physician outcomes in dialysis facilities, it should consider establishing ESRD related measures for the Physician Quality Reporting System (PQRS).”

Other measures

Mineral Metabolism Reporting: The NRAA said it was concerned that the proposed threshold of 97% is too high and will be harmful to small facilities (it made similar comments about the high threshold for anemia management reporting as well). “In most small facilities, even in facilities with 11 or more qualifying cases in the performance period, just one patient can cause a facility to miss the proposed threshold. Unfortunately, the challenge for small facilities is not likely be mitigated by the alternative threshold of the 50th percentile of facilities in CY 2013. Requiring facilities with less than 11 patients to report on this measure is also difficult for these same reasons, even with the one case exception. The NRAA urges the agency to use a lower compliance rate for this measure,” the association wrote.

The NRAA supports the inclusion of home dialysis patients in this reporting measure, but said it was concerned that the proposed compliance rate could discourage increased use of home dialysis. “There are several reasons, such as travel or inclement weather, why a facility might not be able to see a patient on the designated clinic days and would thus not be able to take the appropriate measurements. The proposed compliance rate could be especially difficult for home-only dialysis programs, they added, because of small patient populations.

Hypercalcemia: The NRAA supports the proposal to use a three-month rolling average for this measure. “However, we note that hypercalcemia can be caused by conditions other than ESRD, such as malignancy or sarcoidosis, which may be out of dialysis facilities’ control. We recommend that patients who present with other non-ESRD conditions that may cause hypercalcemia be excluded from the three month rolling average,” they wrote.

NHSN Bloodstream Infections: The NRAA supports the conversion of the reporting measure to a clinical measure, but suggests penalties for clinical outcomes should be delayed until there are established benchmarks and facilities have the opportunity to define practices that will help them meet the benchmark to prevent payment loss. “Facilities have demonstrated practices that reduce the percentage of blood stream infections in dialysis accesses. NRAA can support measures that quantify infection rates. However to date, industry benchmarks for infections have not yet been published so facilities are unable to benchmark their outcomes in relationship to a standardized benchmark,” they wrote.

Co-morbidity Reporting Measure: The NRAA opposes the proposed measure “as it does not measure quality outcomes or the patient experience. We understand CMS’s need to gather data on patient co-morbidities, but this measure is essentially another unfunded mandate for dialysis facilities. This information is currently being reported on the 2728 forms already being submitted through CROWNWeb and is available from claims data,” they said.

NKF: Retire AV fistula measure; be cautious when creating efficiency, cost of care measures

The CAHPS survey appears to be a sore spot for most dialysis organizations responding to the proposed rule for the Quality Incentive Program for performance year 2014. The National Kidney Foundation echoed comments by the Kidney Care Partners and the National Renal Administrators Association criticizing the patient satisfaction survey as being too long and cumbersome. Increasing the requirement to conduct the exam from once a year to twice a year would be overly burdensome to facilities, they said. “NKF believes evaluating all dialysis patients’ satisfaction with their care provides results that are actionable to improve care and quality of life for patients,” the Foundation wrote. “NKF appreciates the Agency’s recognition of the need for the CAHPS survey to be administered by a third party rather than conducted in the facility, which takes attention away from providing direct patient care. However, we remain concerned with the length of the survey as it does require a considerable amount time for patients to complete it and these patients already spend a great deal of their time focused on dialysis. In addition, we encourage CMS to develop a survey that can also be provided to patients who do home dialysis, as their experience with their care is just as important as those who receive in-center dialysis.”

Unlike other organizations, the National Kidney Foundation suggests CMS retire the clinical measure for assessing access care. “While Fistula First is an important goal, the greater clinical importance is catheter reduction as it has the greater impact on improving survival and reducing hospitalizations, infections, and costs. Having a measure for AV fistula and one for catheters also completely ignores that a graft is an appropriate access for some patients who are unable to receive a fistula,” the foundation wrote. “Certain facilities, such as nursing home dialysis units, will face challenges to improve the AV fistula prevalence. In addition, some observational studies have shown that the elderly are less likely to have a successful AV fistula created and ultimately mature to support hemodialysis treatment. As such, measures that focus on catheter limitation are important to emphasize, since these encourage limitation of the vascular access that is associated with the most adverse outcomes.

“However, CMS needs to take into consideration that there are patients with limited life expectancy in whom the catheter is the best vascular access option. Exclusions such as hospice care should be considered accordingly. In addition, access to appropriate vascular access options may be affected by the skills, training and practice patterns of surgeons in the community, which the dialysis facility does not have complete control of.”