Medicare P4P Quality Uncategorized

ESRD Quality Monitoring Initiative

All patients with end stage renal disease (ESRD) are eligible for Medicare regardless of their age.  In 1972, the Social Security Act extended all Medicare Part A and Part B benefits to individuals with ESRD (of any age) who are entitled to receive Social Security benefits. ESRD beneficiaries now account for 1% of Medicare enrollment. This post review the types of services ESRD Medicare beneficiaries receive and how Medicare pays providers for these services.  Today, however, I will review Medicare efforts to improve the quality of care ESRD beneficiaries receive.  You can find an overview of the ESRD Quality Improvement Program (QIP) here.


  • 1972. the Social Security Act extends all Medicare Part A and Part B benefits to individuals with ESRD (of any age) who are entitled to receive Social Security benefits. ESRD beneficiaries account for 1% of Medicare enrollment.
  • 1978. ESRD Amendments require the formation of ESRD Network Organizations to support the ESRD program. CMS currently contracts with 18 ESRD networks.
  • 1994. The Core Indicators Project was established to improve the care of patients with ESRD.  The Core Indicators included measures related to anemia management, adequacy of hemodialysis, nutritional status and blood pressure control
  • 1999 (Mar). ESRD CIP was merged with the ESRD Clinical Performance Measures.
  • 2000 (Jan). Section 4558(b) of the Balanced Budget Act of 1997 required CMS to develop and implement a method to measure and report
    the quality of renal dialysis services furnished under the Medicare program. To implement this legislation, CMS developed the ESRD Clinical Performance Measures (CPM) Project based on the National Kidney Foundation’s Dialysis Outcome Quality Initiative (NKF–DOQI) Clinical Practice Guidelines.
  • 2001 (Jan). Medicare launched Dialysis Facility Compare based on the Nursing Home Compare website. The quality measures initially reported on DFC were measures of anemia control, adequacy of hemodialysis treatment and patient survival. Medicare claims data were used to calculate the anemia management and hemodialysis
    adequacy rates, and administrative data were used to determine patient survival rates.
  • 2008 (Apr). The updated ESRD Conditions for Coverage final rule, which contains revised requirements that dialysis providers and facilities must meet in order to be approved by Medicare and receive payment. As part of the revised requirements, dialysis providers and facilities are each required to implement their own quality assessment and performance improvement program. The CPMs were updated to include 26 measures from the areas of anemia management; hemodialysis adequacy; peritoneal dialysis adequacy; mineral metabolism; vascular access; patient education/perception of care/quality of life; and patient survival.
  • 2008 (Jul). Section 153(c) of the Medicare Improvements for Patients and Providers Act (MIPPA) requires that Medicare implement a quality incentive program (QIP)
  • 2009 (Feb). Medicare began implementing the CROWNWeb system to electronically collect information on about patients, facilities, providers, and clinical data to support the CPM Project.
  • 2009 (Sep). Medicare decides to begin paying ESRD providers based on a prospective payment system (PPS) beginning in 2011.

Where are we now?  Medicare will begin paying dialysis providers through a PPS beginning in 2011.  This will give providers an incentive to provider services more cost effectively, but also potentially will give them an incentive to decrease the quality of care.  To ensure that ESRD beneficiaries receive the same quality of services under PPS as under a FFS, Medicare developed the QIP.  Below, I review the QIP in more detail.

Quality Incentive Program

The QIP requires Medicare to establish an ESRD quality program using the following steps:

  1. Select measures;
  2. Establish the performance standards that apply to the individual measures;
  3. Specify a performance period with respect to a year;
  4. Develop a methodology for assessing the total performance of each provider and facility based on the performance standards with respect to the measures for a performance period; and
  5. Apply an appropriate payment reduction to providers and facilities that do not meet or exceed the established total performance score.

Medicare has already chose quality measures for the initial year.  Data from the following three measures will be submitted to CMS via ESRD claims.

  • Percentage of Medicare patients with an average Hemoglobin <10.0 g/dL (2%);
  • Percentage of Medicare patients with an average Hemoglobin >12.0 g/dL (26%); and
  • Percentage of Medicare patients with an average Urea Reduction Ratio (URR) >65 percent (96%).

The numbers in parentheses represent the national performance rates for all dialysis providers and facilities based on 2008 data from the Dialysis Compare website.  Providers receive a score between 0-10 based on their performance on each measure.  Medicare has recently proposed a scoring method which subtracts 2 points for every 1 percentage point the provider falls below the initial performance standard (e.g., if the initial performance standard for a particular provider or facility for the Hemoglobin>12 g/dL is set as the 2008 national average rate (26%), then if that provider/facility had 28% of Medicare patients with hemoglobin levels>12 g/dL during 2010, the provider/facility would receive 6 points for its performance on the measure as 28% is 2 percentage points below the performance standard). The provider’s total score could be weighted evenly across all three scores.  Alternatively, some have proposed weighting the Hemoglobin <10.0 g/dL at 50% of the score and the other two quality measures at 25% of the provider’s score to put more weight on avoiding low hemoglobin levels.

Payment will be based on the provider’s score.  THe proposed payment reduction scale is as follows:

  • 26-30 points: 0.0%
  • 21-25 points: -0.5%
  • 16-20 points: -1.0%
  • 11-15 points: -1.5%
  • 0-10 points: -2.0%

In the future, Medicare will consider expanding the QIP program to include additional measures.  Quality measures considered include:  Kt/V, vascular access rates, bone and mineral metabolism, and access infection rates.


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