NN&I - January 2012

Renal Policy expected by the end of this month The methodology for the Anemia and Adequacy measures remain essentially unchanged from 2013 The Vascular Access Type measure VAT is a combination of two measures catheter rate and AVF rate Scores will be calculated from data entered on ESRD claims CR 6782 Since claims codes V5 V7 are ambiguous with reference to patients who have both a catheter in place and AV access in use instructions were updated effective Jan 1 2012 CR 7460 to state that if an AV fistula AV graft is used with two needles but the patient still has a catheter in place providers facilities should report the presence of both the catheter and the AV fistula AV graft Since the reporting requirement will be different during the reporting and performance periods it is difficult to assess the impact of this measure on QIP performance Practically speaking we agree that high catheter rates should be penalized However it is becoming increasingly clear that the Fistula First Initiative has not lead to a reduction in the number of hemodialysis catheters We believe that this quality measure will compound the problem by again leaving the possibility of grafts for selected patients out of the equation Furthermore successful access creation and maturation depends not only on actions of the dialysis center and medical director but also on the vascular surgeon Any comprehensive plan to improve rates of AV access in dialysis patients will need alignment of incentives beyond the dialysis center to extend to the pre dialysis nephrologist the hospital and the vascular surgeon or other interventionalist In our own practice we have found some benefit to coordinating access care by hiring a full time access coordinator who facilitates timely access placement monitors for maturation and works in close communication with the nephrologists and vascular team The burden of reporting measures Performance on the anemia adequacy and access measures constitute 90 of the 2014 performance score The remaining 10 are earned by attesting to participating in the National Healthcare Safety Network NHSN Dialysis Event Reporting Measure for Healthcare Associated Infections the Patient Experience of Care Survey the In Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems ICH CAHPS and the Mineral Metabolism reporting measure While these measures are easy to achieve in that they only require participation rather than achievement they do come with some amount of burden At present NHSN reporting needs to be entered manually and the CAHPS survey does require participation by patients Total performance scoring will also be restructured in 2014 with points given for both achievement and performance Since performance standards are not yet finalized the projected impact of the QIP in 2014 is only a rough estimate Based on preliminary data approximately 30 of facilities will have some payment reductions with direct financial impact of about 22 million But when the added reporting and data collection burden is included the costs associated with the 2014 QIP are an estimated additional 25 million adding to a potential aggregate impact of 47 million Pushing forward into a new era of value based purchasing The QIP is defined as a quality program ostensibly rewarding what the CMS ESRD program considers to be high quality care Yet the structure of the program a non payment for nonperformance model is more clearly value based purchasing where CMS is deciding not to pay for outcomes that it does not desire Therefore the 2012 and 2013 QIPs had limited ability to promote timely modifications of provider behavior reducing CMS value buying power In its document Roadmap for implementing value driven health care in the traditional Medicare feefor service program CMS states that a goal of value based purchasing is to move Medicare away from being a passive purchaser of services to an active purchaser of high quality efficient care In fact the bundle itself can be considered a type of valuebased purchasing with the QIP representing a sort of checks and balances system to ensure that CMS defined priorities for high quality care continue to be achieved in the bundled payment system This represents a fundamental shift in the way that CMS views and pays for health care and puts the ESRD program at the forefront in a new era Per CMS estimates the 2014 QIP would take close to 50 million directly out of the ESRD program based on the number of facilities that anticipate not meet their goals This is a substantial financial hit for facilities It is imperative that value is demonstrated by proving that outcomes are improved for patients the key stakeholders in this equation We do believe that the 2014 QIP represents a significant advance over the 2012 and 2013 versions in that new quality measures should address critical health issues in dialysis patients in particular vascular access type and infection We are however concerned about the complexity of the scoring system The new 100 point scale with both Achievement and Improvement measures are not intuitive and do not lend themselves to direct comparison with 2012 and Nephrology News Issues January 2012 Subscribe to our free eNewsletter at www NephrologyNews com 28