NN&I - January 2012

Renal Policy Tackling pay for performance Current and future challenges Premila Bhat MD J Ganesh Bhat MD January 2012 Nephrology News Issues 27 Pursuant to the Medicare Improvement for Patients and Providers Act the prospective payment system for the end stage renal disease program was implemented one year ago This month we are entering the first payment period of the ESRD Quality Incentive Program At this time most facilities have had the opportunity to review their 2012 Performance Score Report which uses their 2010 performance to determine if there is any payment penalty to their bundled payment in 2012 The 2012 QIP was intended as a preliminary effort one that was inevitably imperfect based on limited data and would surely require refinement Only two quality measures anemia and adequacy were defined limiting the scope of influence of the QIP Furthermore large temporal gaps exist between the payment period which started this month the performance period which ended one year ago and the performance standard periods CY 2007 or 2008 2012 Its Penalty not Pay for Performance When we evaluated the Medicare reports on our clinics performance at Atlantic Dialysis Management Services ADMS for the 2012 payment period we saw a small number of facilities that provided high quality care according to our internal quality review and metrics but lost QIP points and were hit with a payment penalty These penalties were all related to small increases in patients with hemoglobin below 10 g dL a metric that has been dropped from the more recent versions of the QIP In our view the recent change in the U S Food and Drug Administration labeling for erythropoiesis stimulating agents and the ensuing shift in proposed QIP performance metrics illustrates some of the dangers in prematurely adopting performance metrics Ensuring patient safety and anticipating any possible adverse clinical consequences is a key feature to preserve the integrity of the QIP While we acknowledge the abundance of evidence linking higher hemoglobin to improved quality of life and other outcomes in the absence of unequivocal data we agree with the decision to retire the www NephrologyNews com Hb 10 g dL measure In our own facilities protocols targeting TSAT 30 to 50 and Ferritin 500 to 800 ng ml have been a key strategy for optimizing ESA use since 2009 In terms of target Hb range our recommendation remains to maintain Hb in an individualized range consistent with current FDA recommendations To ensure that ESAs are not under used we have been tracking Hb levels below 10 g dL below 9 g dL and occurrence of red blood cell transfusion 2013 Same measures more stringent penalties The scope of the 2013 QIP remains limited to two clinical domains weighted equally anemia and adequacy The major difference between 2012 and 2013 QIP however is the much more stringent penalty structure Facilities must achieve a full 30 points to avoid payment reduction CMS projects that approximately 26 of facilities will have some payment reduction based on 2012 performance That measures up to about 24 million taken out of the bundle as compared with the projected 17 million impact in 2012 Theoretically a unit that received 0 penalty in 2012 could have a 1 penalty in 2013 with unchanged performance on quality measures see case study p 29 The stated intent of this more aggressive penalty structure is to promote continuous quality improvement Yet most of the performance period for 2013 had already been completed at the time of publication of the final rule minimizing its potential impact on quality improvement 2014 Moving forward with new measures and a new scale In the proposed rule the QIP for 2014 introduces a collection of new measures on which the nephrology community has extensively commented Ultimately the final rule involved only a small number of these measures namely anemia measure of hemoglobin 12 g dL adequacy URR 65 and access a combination measure of percentage of patients with AV fistula and catheter The baseline performance period will be shifted from July 1 2010 to June 30 2011 and the performance period will start Jan 1 2012 These changes will serve to make the baseline period more contemporaneous with current practices and facilities will have opportunity to modify practices in CY 2012 in response to the publication of performance standards The nephrologists are with Atlantic Dialysis Management Services a physician practice that owns and operates 13 dialysis clinics in the New York area Premila Bhat is also a member of NN Is Editorial Advisory Board