Issue: June 2021
Disclosures: Sheetz reports no relevant financial disclosures.
June 17, 2021
3 min read
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Almost a decade later, ESRD Quality Incentive Program shows little impact on quality

Issue: June 2021
Disclosures: Sheetz reports no relevant financial disclosures.
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CMS has a history of using ‘financial carrots’ to influence treatment approaches in the ESRD Program.

In 2004, CMS Administrator John Scully changed the formula for the monthly capitated payment to nephrologists from a lump sum to a fee-for-service system. His rationale was patients would see their nephrologists more often, leading to better quality care.

Mark E. Neumann

Visits increased substantially, but published studies have showed they did little to improve the quality of care. “ ... [T]his did not translate into meaningful improvements in health outcomes at the population level, and there is no evidence that the policy of paying physicians to see patients more frequently yields any benefits,” Baylor College of Medicine nephrologists Samaya J. Anumudu, MD, and Kevin Erickson, MD, wrote in a 2020 paper published in Seminars in Dialysis.

Quality measures

The agency then turned to assessing quality and, after tracking and reporting on some basic quality measures and seeing some improvement, launched the ESRD Quality Incentive Program (QIP) in 2012. The program was aimed at increasing quality at poor-performing facilities. Centers that did well were “incentivized” by being paid at the current composite rate; clinics with lower performance scores saw a drop in payment of up to 2%.

In a recently published paper in Annals of Internal Medicine, Kyle H. Sheetz, MD, MSc, and colleagues from the University of Michigan’s Center for Healthcare Outcomes and Policy, and Center for Evaluating Health Reform reviewed QIP data from 2017 to 2018 covering 5,830 outpatient dialysis centers to determine whether the program led to improvement in quality.

Of that group of dialysis clinics, 1,109 (19%) received penalties in 2017 on the basis of performance.

Sheetz and colleagues concluded the QIP penalties on poor-performing facilities did little to improve quality in areas such as vascular access and anemia management.

“Penalization was not associated with improvement in total performance scores in 2017 or 2018,” they wrote. “This was consistent across dialysis centers with different characteristics. There was also no association between penalization and improvement in specific measures.”

Center characteristics

The authors pointed out the characteristics of centers that faced financial penalties – location and patients treated – suggested the QIP hurt clinics that needed help the most.

“Penalized centers were located in ZIP codes with a higher average proportion of non-White residents (36.4% vs. 31.2%) and residents with lower median income ($49,290 vs. $51,686),” the authors wrote.

In response to questions posed by Nephrology News & Issues about the conclusions of the study, Sheetz said, “It’s not that financial incentives are a bad idea, per se,” he said. “It’s probably more about the tradeoffs we’d be willing to accept in order to make the financial rewards/penalties a more powerful carrot/stick.

“For example, increasing the size of financial penalties may serve as an important incentive for dialysis centers to improve quality across a wide range of domains. However, this may also place disproportionate strain on dialysis centers that operate on tight margins or are located in areas with less resources (ie, poorer communities),” he said.

He added, “So, one might find the unintended consequences of that option to be more detrimental to the ultimate goal of improving care for patients.”

Sheetz said the study offers a couple of ideas on how CMS could improve the QIP to generate meaningful results.

“The quality measures change often. This doesn’t allow centers, particularly those with limited resources, to plan ahead and make actionable changes. Sticking with a certain set of outcomes for longer periods of time might help,” he said.

“It’s also possible that a broad menu of outcomes leads to diffuse efforts and therefore limited impact. Focusing on the outcomes that are critical or most proximate to patients might help centers concentrate the efforts. It also provides centers with more flexibility to address key outcome measures, rather than directing effort to a broad set of intermediate outcomes.

“We spend a lot of money on dialysis in this country,” Sheetz said, “so it’s not as simple as ‘throw money at the problem.’”