ESRD Quality Incentive Program

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Quality Incentives for ESRD Care
Reimbursing physicians based on the quality of care they
provide is not a new idea. In the 1700s B.C. in ancient Babylon, Hammurabi’s
Code stated “If a physician operates on a man for a severe wound with a bronze
lancet and causes the man’s death…they shall cut off his hand.” Over the past decade, we have seen a revolution in quality measurement
and physician reimbursement based on outcomes. Nephrology has been a leader in
this movement, particularly in ESRD care. 
How did the ESRD Quality Incentive Program Begin?
The Centers for Medicare and Medicaid Services (CMS) has
been paying for dialysis since 1972. The Social Security Amendments of 1972,
Section 299I established that people with “chronic renal disease and who
requires hemodialysis…shall be deemed disabled for the purposes of coverage.” However,
it wasn’t until 2008 that reimbursement was linked to quality measures.  On July 15, 2008, Congress passed the Medicare Improvements
for Patients and Providers Act (MIPPA).
MIPPA added a sub-section to the Social Security Act called the ESRD Quality
Incentive Program (ESRD QIP), which changed how dialysis was reimbursed by
linking quality incentives to dialysis payments. ESRD QIP went into effect in
What is the ESRD QIP?
The ESRD QIP is the first mandatory pay-for-performance
initiative set by Medicare. Dialysis units are required to report a number of
quality measures to Medicare. These measures are divided into “clinical”
measures and “reporting” measures.  Clinical measures are scored based on two factors:
1) Achievement — compares a unit’s performance with
dialysis units nationally
2) Improvement — compares a unit’s performance to
their previous year’s performance

Reporting measures only require dialysis units to submit their
data, but are not graded based on performance.  In 2018, there are 11 clinical measures and 5 reporting

The 11 clinical measures are divided into 3 subdomains
assigned different weights: Safety (20%), Patient and Family Engagement/Care
Coordination (30%), and Clinical Care (50%). Each measure is given a score of
0-10, and a Total Performance Score is calculated by weighting the individual
scores. A full summary of the 2018
program can be found here.

What’s the Incentive?
Dialysis units face a payment penalty of up to 2% of total
reimbursement based on their Total Performance Score:
Performance Score
49 to 100
No reduction
39 to 48
29 to 38
19 to 28
0 to 18
Performance on quality measures is converted into a Star
Rating, which in addition to the Total Performance Score, is posted on CMS’s Dialysis
Facility Compare website.  Check out your
dialysis unit’s performance here.
Why should you care about ESRD QIP? 
Renal fellows (you!) will be future leaders and medical
directors of dialysis units.  We will be
reporting these quality measures to CMS, leading quality improvement projects
to improve the metrics, and conducting research to determine whether these
metrics are valuable in improving patient care.  These quality measures directly impact how dialysis units
take care of patients and where resources are allocated to collect data and
improve performance. For example, dialysis unit social workers may be tasked
with administering the In-Center Hemodialysis Consumer Assessment of Healthcare
Providers and Systems (ICH CAHPS) and
working with patients and families to improve patient satisfaction.

What has been the effect of ESRD QIP?  
ESRD QIP was designed to improve the quality of care for
dialysis patients.  Has it delivered on
this promise?  In our next post, we will cover
data on the effect of ESRD QIP on quality measures, focusing on the
Standardized Readmission Ratio (SRR).
Read more about the ESRD QIP in this JASN
and on the CMS
Sri Lekha
Tummalapalli, MD, MBA
NSMC Intern 2018
Fellow, UCSF

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