Study: Dialysis care has not improved under ESRD Quality Incentive Program
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The ESRD Quality Incentive Program, launched nearly a decade ago, has done little to improve the quality of care of patients on dialysis, according to a recently published study.
“Despite its scope, the ESRD [quality incentive program] QIP has not been independently evaluated, and it remains unclear whether the quality of care at outpatient dialysis centers has improved as a result,” Kyle H. Sheetz, MD, MSc, and colleagues from the University of Michigan’s Center for Healthcare Outcomes and Policy, and Center for Evaluating Health, wrote in outlining the purpose of the study.
“Recent work suggests that patients treated at centers with lower program quality scores have a higher risk for death in their first year on dialysis. However, there is also evidence that dialysis centers are more likely to receive penalties if they are located in areas with lower household incomes or a higher proportion of ethnic minority residents, or in which more beneficiaries are dually enrolled in Medicare and Medicaid.
“This raises questions about whether the program is accurately measuring center quality or whether differences across centers are driven by underlying patient characteristics.”
CMS launched the program in 2012 with a set of quality measures linked to performance scores. Dialysis facilities that did not meet the performance scores faced financial penalties of up to 2%.
The program operates in 3-year cycles. CMS records performance in the first year, evaluates and notifies dialysis clinics of the results in the second year, and releases the list of clinics facing penalties in the third year.
In their evaluation, Sheetz and colleagues reviewed ESRD QIP program data from performance year 2015 and penalties assessed in 2017. “Centers received notification of these penalties in mid-2016,” they wrote. “Notification occurs over a 1-month preview period during which centers receive details about their performance and can ask for clarification on how their scores were calculated. This analysis examined whether penalization was associated with changes in dialysis center performance in 2017, the year in which they were penalized, or in 2018, which allowed for additional time to respond to the penalty.”
In the 9-year history of the program, CMS has dropped and added performance measures, as well as change how the performance score is determined. In 2021, dialysis providers are being evaluated on 14 performance measures, which include the following:
- hospitalization and readmission rates;
- patient satisfaction surveys;
- the percentage of prevalent dialysis patients waitlisted for transplant;
- clinical depression screening;
- Kt/V dialysis adequacy;
- vascular access (arteriovenous fistula rate and long-term catheter rate);
- transfusion ratio;
- hypercalcemia;
- ultrafiltration rate;
- blood stream infection rate;
- dialysis event reporting; and
- medication reconciliation.
Sheetz and colleagues evaluated some of those measures used in the 2015 performance year, including the arteriovenous fistula and catheter utilization rate, dialysis adequacy, bloodstream infections, hospital readmission rates, patient satisfaction and anemia management.
Of the 5,830 dialysis centers that were evaluated for performance in 2015, researchers identified 1,109 that received penalties to the ESRD QIP.
Study results
Results showed the financial penalties did not change the level of care for patients treated at those clinics.
“Penalization was not associated with improvement in total performance scores in 2017 or 2018,” Sheetz and colleagues wrote. “This was consistent across dialysis centers with different characteristics. There was also no association between penalization and improvement in specific measures.”
The authors noted the characteristics of centers that faced financial penalties – location and patients treated – suggested the QIP hurt clinics that needed help the most.
“Penalized centers were located in ZIP codes with a higher average proportion of non-White residents (36.4% vs. 31.2%) and residents with lower median income ($49,290 vs. $51,686),” the authors wrote.
In comments about the study, Sheetz told Healio Nephrology: “It’s not that financial incentives are a bad idea, per se. It’s probably more about the tradeoffs we’d be willing to accept in order to make the financial rewards/penalties a more powerful ‘carrot’/stick.
“For example, increasing the size of financial penalties may serve as an important incentive for dialysis centers to improve quality across a wide range of domains,” Sheetz said. “However, this may also place disproportionate strain on dialysis centers that operate on tight margins or are located in areas with less resources (ie, poorer communities).”
He added, “So, one might find the unintended consequences of that option to be more detrimental to the ultimate goal of improving care for patients.”
Program changes
Sheetz said the study offers several ideas on how CMS could improve the QIP to generate meaningful results.
“The quality measures change often. This doesn’t allow centers, particularly those with limited resources, to plan ahead and make actionable changes,” Sheetz said. “Sticking with a certain set of outcomes for longer periods of time might help.
“It's also possible that a broad menu of outcomes leads to diffuse efforts and therefore limited impact. Focusing on the outcomes that are critical or most proximate to patients might help centers concentrate the efforts. It also provides centers with more flexibility to address key outcome measures, rather than directing effort to a broad set of intermediate outcomes.
“We spend a lot of money on dialysis in this country,” Sheetz said, “so it’s not as simple as ‘throw money at the problem.’”
References:
Sheetz KH, et al. Ann Int Med. 2021;doi:10.7326/M20-6662.
www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP.
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