Does the ESRD QIP Really Drive Quality Improvement—or Risk Patients?

In 2012, CMS launched the ESRD Quality Improvement Program (QIP),
under which data are collected during a specific calendar year and
reductions—if any—take place 2 years later. So, for example, data
collected in calendar year (CY) 2010 affected Medicare reimbursement for
dialysis in payment year (PY) 2012. To learn if a clinic has a payment
reduction, each measure is weighted and summed to yield a “total
performance score” (TPS). If the TPS is too
low, CMS reduces payment for each of the clinic’s patients for
the whole year by 0.5%, 1.0%, 1.5%, or 2%, depending on
how low the TPS is.

According to a fact sheet CMS
published in November 2011, “The QIP is designed to improve
patient outcomes by establishing payment incentives for
dialysis facilities to meet performance standards established by CMS.
Under the ESRD QIP, for the first time, payments are tied to the
quality of care beneficiaries receive at the
facilities.” Questions this blog will
attempt to answer are: What does the ESRD QIP measure, and how? How
many facilities have payment reductions? How do payment cuts affect
clinics: And, are there unintended
consequences of the ESRD QIP?

What Does the ESRD QIP Measure, and How?

The four tables below describe the ESRD QIP for a specific payment
year. Each table includes:

• List of measures

• Performance period when data are reported

• Comparison period if applicable (PY 2014 on)

• Performance standard

• Measure weighting

• Minimum data requirements (minimum cases per measure to be
  counted)

• Low-volume facility adjustment if applicable

• Maximum total performance score (PY 2012-2016 only)

• Minimum total performance score

• Payment reduction scale (PY 2012-2016 only)

• Information about reporting measures (PY 2012-2016 only)

What follows is a table showing how the QIP measures and the TPS
changed over time. The sources are for a table that goes into greater
detail.

Sources:

How Many Clinics Have
Payment Reductions?

Dialysis clinics strive to avoid Medicare payment cuts. Clinic
managers want to meet or exceed measure targets during the calendar year
when data are reported. To find out how many clinics have reimbursement
cuts, I downloaded the QIP data for PY 2021, 2022, and 2023. I learned
that although CMS data files for PY 2022 and 2023 include data for QIP
measures, due to the COVID-19 public health emergency (PHE), CMS
chose not to reduce any clinic’s payment for those years and
the database had “NA” in the payment reduction column. The PY 2021 data
collected during 2019 were reported the year before COVID-19 PHE. That
file included performance scores and payment reduction percentages. In
CY 2021, clinics whose TPS was 57 or higher had no reduction. Below are
dialysis companies with 100 clinics or more and the numbers of
reimbursement cuts.

Green shading indicates percentage(s) better than the national
average indicated in green text.

*NOTE: These data do not reflect companies acquired but not listed as
owned by entities in the table. These include a few clinics designed as
DSI, Gambro, Liberty Dialysis, Renal Care Group, and Renal Ventures. The
table also does not include companies with fewer than 100 clinics.

How do payment cuts affect clinics?

In CY 2021, 61% of dialysis clinics had no Medicare payment
reduction and 33% had cuts of 1% or less. Just 5% had
cuts of 1.5% or more. A higher percentage of US Renal Care
(52%) and clinics CMS described as “independent” (47%) had reimbursement
cuts.

In CY 2021, the Medicare allowed charge under the base ESRD
prospective payment system (PPS) that year was $253.13. Medicare
routinely pays 80% of that amount per patient per treatment for 3 HD
treatments/week or 156 HD treatments per patient per year. PD payment
for 7 days is the same as a week of HD. So, assuming the QIP cut is from
what Medicare would pay a clinic that received no QIP cut or $202.50
(80% of the ESRD PPS) then:

• A loss of .5% or $1.01 per
  patient/treatment x 156 = $157.56 less per
  patient/year.

• A loss of 1% or $2.03 per
  patient/treatment x 156 = $316.68 per patient per
  year.

• A loss of 1.5% or $3.04 per
  patient per treatment x 156 = $474.24 per patient per
  year.

• A loss of 2% or $4.05 per
  patient per treatment x 156 = $631.80 per patient per
  year.

The larger the dialysis organization, the lower the impact if one or
a few clinics have cuts. And large dialysis organizations (LDOs) can
share clinical expertise and data across clinics under their management.
They may be able to identify areas needing improvement more
easily. This gives them an advantage in being able to develop
and implement interventions to improve future QIP scores.

Are There Unintended Consequences of the ESRD
QIP?

Dialysis Facility Compare uses some QIP data to determine how many
stars (1-5) a clinic has. A study of these data from October 2015 to
April 2018 found that the percentage of clinics with 4 or 5
stars increased from 30% to 53.4%. Independent clinics had
lower odds than LDOs of showing year-to-year-improvement.

Studies of QIP goals and outcomes have had some interesting
findings:

• A study that looked at the QIP goals for vascular access rates
  found the goals of reducing catheters to below 10% and increasing
  fistulas to 68% were not achieved. The authors reported lower
  fistula rates in clinics treating patients in Black Zip Code Tabulation
  Areas where incomes were under $45,000.

• A study looking at social risk factors found that clinics
  that treated a higher proportion of Black and dual eligible patients
  were more likely to have reimbursement cuts and patients with worse
  outcomes.

• Another study found that facilities with more patients who had
  higher comorbidities, were Black, or had Medicare and Medicaid had lower
  QIP scores. Mortality rates were higher in clinics with low
  scores and rose as reimbursement cuts increased. Clinics with
  better QIP scores the following year had lower death rates.

If a single independent clinic or a clinic in a small chain has a low
score that results in a reimbursement cut, might that cause
greater financial stress on a single clinic or small chain than on a
large one? Independent clinics and small chains may not have
the same personnel expertise, data resources or financial reserves as an
LDO. Revenue loss combined with lack of other resources to improve a
clinic’s QIP score might target a clinic for closure or acquisition
or encourage a clinic to refuse to treat patients requiring more
time and effort because of their more challenging needs.

I don’t think we know how much social determinants of health
contribute to a clinic’s QIP score and negative patient
outcomes. In the 2024
proposed rule for the ESRD prospective payment system and QIP, CMS
proposes to add a Screening for Social Drivers of Health measure and a
Screen Positive Rate for Social Drivers of Health reporting measure. If
these remain in the final rule, researchers will be able to look more
closely at whether the QIP as currently designed contributes to health
inequities and penalizes smaller clinics as well as those that treat
patients with more complex medical and psychosocial needs.

• Source: https://homedialysis.org/news-and-research/blog/570-does-the-esrd-qip-really-drive-quality-improvement-or-risk-patients