The Dialysis Quality Incentive Program rule proposed - CMS calls for comments

By Bill Peckham 

On Monday the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on the quality incentive program (QIP) required by Section 153 of MIPPA. Reading the 77 page PDF and the CMS Fact Sheet the proposal is about what was expected as a QIP starting point. 

The proposal is to use just three dialysis quality measures: Hemoglobin above 12; Hemoglobin below 10; URR above 65%, this represents no change from the QIP outline released in September. However, in response to comments received as part of the greater bundle comment process, CMS proposes to weight Hgb <10 as the most important of the three measures. Hgb <10 will count for 50% of your score, the other two measures will each count for 25%.

The PDF explains a pretty elaborate scoring system - it's a 10 point system for each of the three measures that together generates a Total Performance Score on a 30 point scale (30 is the highest score you can get), performance is measured against 2008 national averages (or 2007 unit performance, if it is lower) and the withhold is in .5% increments. 

CMS estimates that  3,205 units will see no payment reduction in 2012 because they will achieve a Total Performance Score (TPS) above 26. CMS estimates 709 units will see a 0.5% payment reduction due to TPS of 21 to 25; 183 units will see a 1.0% payment reduction for TPS between 16 and 20; 184 units will see a 1.5% payment reduction for TPS between 10 and 15; and only 30 units will see a 2.0% payment reduction for TPS 10 or below. In total CMS estimates that between 17 and 18 million dollars will be withheld in 2012.

Given the industry receives around 9 billion dollars a year in Medicare payments, 17 million dollars does not seem like very much but the basic framework of the QIP was created by Congress, not CMS. CMS does request comments on a number of specific points, page 48:

We are particularly interested in comments on how we can educate Medicare beneficiaries and their families about the presence of certificates in dialysis providers/facilities and how the information can be used to engage in meaningful conversations with their dialysis caregivers and the clinical community about the quality of America’s kidney dialysis care.

The certificates will report the facility's TPS.

Hmm ... "meaningful conversations with their dialysis caregivers and the clinical community about the quality of America’s kidney dialysis care" is a tall order from urea and hemoglobins under 10, but it is an invitation to give CMS your thoughts. I'd just turn the question around:

What would have to be reported by the TPS for it to inspire beneficiaries to have "meaningful conversations with their dialysis caregivers and the clinical community about the quality of America’s kidney dialysis care"?

Comments are due September 24th.

Comments

[somerville]

Since proper EPO dosing and hemoglobin targets remain an area of intense dispute in dialysis, it seems inappropriate to adopt this clumsy 'one size fits all' numbering system for hemoglobin targets and assign incentives for remaining within them for all patients. Should men, who may have a normal hemoglobin level around 140, be kept at the same hemoglobin level as women, whose normal value is around 120, just because they are on dialysis? What about males whose historical hemoglobin values prior to renal disease were in the 160s? Should the same hemoglobin ranges for dialysis apply to them? What about diabetics, whose vascular complications are worsened by low hemoglobin values? Do the same risk-benefit formulae for hemoglobin targets apply to them on dialysis? Since all these issues are open questions, any administrative policy which acts as if these issues were settled is bound to harm dialysis as an evolving science as well as dialysis patients.

[Anna Bennett]

Somerville/Henry,

At this point, I can't even presume an alternative other than blanket ranges for hemoglobin. The abuses in dialysis with ESA's were/are so egregious, this was the solution.

As a scientist, how would you do it? How would you formulate the equation? I really am curious, because the oversight of this industry is Herculean and I marvel at the complexities, but as recent history has proven, oversight is needed now more than ever.

And I was so happy to see your final few words:

"...is bound to harm dialysis as an evolving science as well as dialysis patients."

Dialysis is an evolving science (although the RX back in the 60's should be the norm today!)

Thank you Henry for being part of the evolution.

Although I am still more of a revolution kinda gal ;)

[Bill Peckham]

The over 12 measure is essentially a gimme under the QIP. The bar for these measures are the 2008 national averages. This means in 2010 - this year - a unit must meet or exceed having fewer than 26% of their patients with a Hgb >12.

This should not be a problem in a post bundled environment when EPO is a cost. This is why in the proposed rule CMS deemphasized Hgb >12, weighting it to count towards 25% of your overall TPS. Hgb <10 counts towards 50% of your score.

The challenge will be meeting the 2008 outcome for Hgb <10. In 2008 only 2% of people on dialysis had a Hgb <10.

If this year, January to December 2010, your unit has 7% of their patients (or more) with a Hgb <10 they would have at most a 15 TPS, which would mean they would loose 1.5% on their 2012 reimbursement. So the incentives are pushing in the direction you'd wish but the amount at risk is out weighed by the financial benefit of using less EPO.

2% of the new base rate is about $5 or 500u of EPO. In very round terms but if dosing comes down to finances the money at risk won't be enough to outweigh the money to be gained.

10 and 12 came from the FDA approved label. Amgen is free to work to change the label but it would be strange for CMS to structure the QIP to support something other than FDA approved label indication for dosing targets.

[Bill Peckham]

I should mention that that the proposal is to measure a unit's 2010 preformance against the 2008 national average OR the unit's 2007 preformance, whichever is lower.

So if a unit in 2007 had 8% of their patients with Hgb <10 that would be their bar in 2010, instead of the national rate of 2%.

The proposed rule is only for 2012, CMS seems very open to suggestions for future years.