Understanding Annual Changes to CMS’ ESRD Quality Incentive Program

The End Stage Renal Disease (ESRD) Quality Incentive Program (QIP), overseen by the Centers for Medicare & Medicaid Services (CMS), helps promote high-quality services in dialysis centers that treat patients with ESRD.* Implemented in calendar year (CY) 2010 / payment year (PY) 2012, this pay-for-performance program links a portion of each payment directly to a center’s performance on select quality measures. Centers that do not meet or exceed the minimum total performance score (TPS), which is a composite score ranging from 0 to 100 that is calculated for all centers, will receive a payment reduction between 1/2 and 2%, depending on how far below this threshold a center performed.

While the principles guiding the ESRD QIP remain the same year-over-year, the program’s specific measures and weights change. It is, therefore, important to review the changes to the ESRD QIP annually, and ensure you are driving toward the latest requirements.

QIP CY 2017 / PY 2019 Changes

Changes to the ESRD QIP, with regard to metrics and weighting, were minor for CY 2017 and are discussed in detail below. The most significant change was an increase of the required minimum TPS from 49 to 60. Therefore, a center will need to achieve a minimum TPS of 60 to not incur a penalty reduction in PY 2019.

Historically, the ESRD QIP measures were divided into two domains: clinical and reporting. However, starting in CY 2017, a new safety domain will be added. Thus, the scoring distribution across the domains for CY 2017 is 75% to the clinical measures, 15% to the safety domain and 10% to the reporting measures. Changes within each domain are outlined below.

Changes to Clinical Measures (75%  of the TPS)

There were no new clinical metrics. However, the weighting of select metrics decreased:

• Adequacy from 16.2% to 14.25% of the TPS
• Access from 16.2% to 14.25% of the TPS
• Hypercalcemia from 6.3% to 6.0% of the TPS

And the weighting of select metrics increased:

• CAHPS from 18% to 19.5% of the TPS
• Standardized Readmission Ratio (SRR) from 9% to 12% of the TPS
• STrR from 6.3% to 9% of the TPS

Previously, there were separate goals for adequacy based on modality. This was updated to an overall goal of 97.74%, which will make it easier for HD (previous goal was 99.43%) and more difficult for PD (previous goal was 97.06%) to obtain all QIP points for this metric.

The hypercalcemia metric was updated such that missing labs or not reporting values in CROWNWeb will negatively impact performance.

Addition of the Safety Domain (15% of the TPS)

The new safety domain includes one existing QIP measure (standardized infection ratio [SIR]) and a reintroduced reporting measure (National Healthcare Safety Network [NHSN] Dialysis Event Reporting):

• Standardized Infection Ratio (9% of the TPS): While the measure is not changing, the weighting is being significantly decreased from 18% to 9%.
• NHSN Dialysis Event Reporting (6% of the TPS): This measure requires that centers report all bloodstream infections to the Centers for Disease Control and Prevention (CDC). This is a reintroduced measure that was last included in CY 2013 requirements.

Reporting Measures (10% of the TPS)

There were no changes to reporting measures.

Conclusion

The ESRD QIP changed the way CMS pays for the treatment of patients with ESRD and was the first program of its kind for Medicare. This pay-for-performance system can impact each dialysis center in three ways: 1) Payment reductions can apply, reducing the revenue received for Medicare treatments furnished; 2) the QIP score is published in the lobby for the public to view and 3) ESRD QIP scores are available online at Dialysis Facility Compare. In addition to reducing payments to low-performing centers, the ESRD QIP provides a means of comparison across centers and promotes transparency. Year over year, the system grows in complexity; thus, it is increasingly important to understand the changes.

* To be eligible for the ESRD QIP, a center must qualify for at least one clinical measure and one reporting measure. There are specific eligibility requirements for each measure, but typically a center needs to have at least 11 patients over the course of the entire performance period to be eligible. All modalities (hemodialysis [HD] and peritoneal dialysis [PD]) and both adult and pediatric patients are included in the ESRD QIP. Due to varying data sources across the measures, some include private pay and Medicare patients while others include Medicare patients only.