Issue: August 2021
Disclosures: Aronoff, Bellovich, Pflederer, Sheetz and Weiner report no relevant financial disclosures.
August 18, 2021
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As financial incentives prove ineffective, kidney community takes steps to improve quality

Issue: August 2021
Disclosures: Aronoff, Bellovich, Pflederer, Sheetz and Weiner report no relevant financial disclosures.
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Quality improvement is a broad term as it applies to health care, and as a major payer for the End-Stage Kidney Disease Program, CMS has tinkered with efforts to influence clinical performance and reduces costs.

Most recently, criticism has been leveled at the agency concerning the management of the ESRD Quality Incentive Program (QIP), a 10-year effort using a pay-for-performance approach to improve the quality of care of patients on hemodialysis.

“I believe the QIP is fundamentally flawed because it is entirely penalty based,” Timothy A. Pflederer, MD, an interventional nephrologist and president of the Renal Physicians Association, told Nephrology News & Issues. “The opportunity of reward is a more powerful motivator than that of penalty avoidance.”

The QIP is the first program in Medicare that pays for the treatment of patients by linking a penalty– up to 2% of the payment a dialysis facility receives for Medicare patients – directly to the performance of facilities on clinical performance measures (CPMs).

CMS publicly reports facility ESRD QIP scores and payment adjustments on Dialysis Facility Compare on the Medicare.gov website. In addition, each facility is required to display a performance score certificate that lists its total performance score.

Mary Dittrich, MD, FASN, chief medical officer for U.S. Renal Care and a member of the steering committee for the Kidney Care Quality Alliance, said there is a need to develop performance measures that are meaningful to patients and address health inequities.

Source: U.S. Renal Care

Recent published reports examining the success of the program, however, concluded that little has changed in key clinical indicators since the program’s inception.

“Penalization [in the QIP] was not associated with improvement in total performance scores ... there was also no association between penalization and improvement in specific measures,” Kyle H. Sheetz, MD, MSc, and colleagues from the University of Michigan’s Center for Healthcare Outcomes and Policy, and Center for Evaluating Health, wrote in an article published in Annals of Internal Medicine earlier this year. The study examined the impact of financial penalties levied by the QIP on dialysis clinics that failed to attain certain performance scores.

A second study published in the Journal of Vascular Access reached similar conclusions about the value of the QIP in reducing the use of catheters and increasing the number of arterio-venous fistulas (AVFs).

“As one of the first financial QIPs in health care, the ESRD QIP has not achieved the stated goals of the CMS to increase AVF access rates above 68% and reduce long-term [temporary dialysis catheter] TDC clinical rates below 10%,” Sapan Shah, MD, and colleagues from Albany Medical College wrote. “Systemic disparities in race, geographic region, economic status, health care access and education of providers and patients prevent successful attainment of goal metrics.”

Shah and colleagues also suggested “a more insightful and comprehensive look into the incentive structure of the ESRD QIP is needed, inclusive of the input of dialysis care providers.”

Dialysis providers vs nephrologists

Despite questions about whether financial incentives, either as a penalty or reward, are effective, CMS is including them in its ESRD Treatment Choices (ETC) model, a mandatory program that started in January for 30% of the dialysis clinics in the United States. In the ETC model, dialysis providers receive bonus payments for placing more patients on home dialysis or referring them for a transplant.

Kyle H. Sheetz

But financial incentives, or “pay for performance,” should be looked at differently for nephrologists vs. dialysis providers, Pflederer said. The Fistula First Breakthrough Initiative, which was successful in the early 2000s at increasing the use of AV fistulas – but did not offer any financial incentives – and the QIP “are facility focused programs with only QIP having direct financial incentive,” he said.

Similar incentives for nephrologists fail to deliver on improving care, Pflederer said. “Nephrologists want opportunity to improve their patient’s health, lower health care costs. Benefit financially from that effort,” Pflederer said. “They want to be freed from unnecessary regulation so that they can bring value to patients and payers in innovative ways.”

Daniel Weiner, MD, MS, an associate professor of medicine at Tufts University School of Medicine and a nephrologist at Tufts Medical Center who has helped to evaluate and interpret the impact of quality metrics on kidney care, told Nephrology News & Issues that the Fistula First Breakthrough Initiative was successful because clinicians acknowledged changes were needed.

“When Fistula First started, there was a huge performance gap between where dialysis care should be and where it was,” Weiner said. “Drawing attention to this gap and changing practice through education and other policies was sufficient to result in marked changes – largely because as a community we were performing so poorly at the start.”

In an interview with Nephrology News & Issues, Sheetz said financial incentives do have promise. ”It is not that financial incentives are a bad idea, per se. It is probably more about the tradeoffs we would be willing to accept in order to make the financial rewards/penalties a more powerful carrot/stick.”

Weiner agreed.

“I think that financial incentives can very much drive practice patterns and that a QIP is a helpful idea,” he said. “The major issue with any quality incentive program based on administrative data is how to incorporate the individual patient reasons for specific care or laboratory results, as well as how to define what is good and what is not good.”

Fewer measures

Much of the criticism of the QIP has been directed at the number of CPMs added in the last decade. The agency now has 14 measures to evaluate clinical performance.

In its June 2019 report, members of the Medicare Payment Advisory Commission, said: “The commission’s principles for quality measurement call for using a small set of population-based outcome, patient experience and value measures.

Daniel Weiner

“Over the past several years, the commission has expressed concern that Medicare’s quality measurement programs are ‘overbuilt,’ relying on too many clinical process measures that are, at best, weakly correlated with health outcomes of importance to beneficiaries and the program.”

Weiner agreed that CMS has added too many measures.

“In my opinion, each measure needs to be revisited with the perspective not only of the broader health of the population but also with the perspective of the individual dialysis patient whose care is assessed by the metric,” Weiner said, “to enhance the program to best meet the needs of the population while also guaranteeing that individualized care can be delivered.”

In both the recently introduced U.S. Senate and the House versions of the Chronic Kidney Disease Improvement in Research and Treatment Act (S. 1971; H.R. 4065), language calls for a review of the QIP to determine if fewer measures would be more effective.

According to the legislation, “[Title 3] would reform how CMS adopts measures used in the ESRD Quality Incentive Program (QIP) to ensure there are a parsimonious set of meaningful, valid and reliable measures,” according to the legislation. “It would establish QIP bonus payments for facilities exceeding the attainment performance standards. It would also improve patient decision-making by eliminating contradictions between the ESRD QIP and Five Star programs.”

Guidelines vs CPMs

Weiner is part of an effort by Kidney Care Partners (KCP), an advocacy group with members from industry, patient and kidney care associations, to develop new CPMs.

Initially launched in 2005, KCP is set to restart the Kidney Care Quality Alliance (KCQA), a quasi-independent organization of KCP that develops dialysis facility-level performance measures for use in programs like the QIP and in the ETC model.

“Our goal is to not only develop performance measures that are empirically sound but that have community support,” KCP said in a statement.

In 2005, the KCQA successfully developed seven CPMs that were endorsed by the National Quality Forum (NQF) in vascular access, immunization, patient education, fluid management and medication management.

With the re-launch, the KCQA – co-chaired by George Aronoff, MD, vice president of clinical affairs for DaVita Kidney Care, and Michigan nephrologist Keith Bellovich, DO, president-elect of the Renal Physicians Association – will focus primarily on home dialysis and transplant, while also addressing anemia management, bone mineral metabolism and blood stream infections.

Performance measures go beyond practice guidelines in helping to improve the quality of care, Aronoff told Nephrology News & Issues. “Performance measures have to be statistically sound and have to be actionable,” he said. “Measures can’t be overly burdensome to patients or providers.”

Mary Dittrich, MD, FASN, chief medical officer for U.S. Renal Care and a member of the steering committee for the KCQA, said, “We need to develop performance measures that are meaningful to patients and address health inequities.”

Likewise, for practicing nephrologists, CPMs “need to be succinct, distinguishable, and readily accessible to all, not only in their delivery but in their measure about how you judge your performance,” Bellovich told Nephrology News & Issues.

KCP anticipates the first measure, which will focus on improving access and retention in home dialysis, will be submitted to the NQF for endorsement by early 2022.

Lessons on quality care

Pflederer said the kidney community learned some important lessons from the Fistula First Breakthrough Initiative – goals can change as patient needs change. “Increasing fistula prevalence from the levels in 2001 was critically important but there were unintended consequences along the way,” Pflederer said. “We learned from those consequences and corrected course – from ‘Fistula First’ to ‘Fistula First, Catheter Last’ – and now to the better approach today that advocates the access type should match the patient’s overall ESKD life plan.

“We still have work to do to make access improvements, but I doubt that worrying about whether an ESRD population prevalence of 60% vs. 70% fistulas will matter.

“The problem of optimal vascular access is best solved within an alternative, value-based payment model where all providers’ and physicians’ financial interests are aligned with the best care of the patient,” Pflederer said. “Value-based care, not ‘incentive payments/penalties,’ are where the quadruple win will be found for patients, physicians, other providers and payers.”

If Congress and CMS agree on reform of the QIP, reviewing a paper published in 2003 and co-authored by nephrologists and officials at CMS on the impact of the CPM project might be beneficial.

Entitled, “Improving the care of ESRD patients: A success story,” the authors detail significant improvement in CPMs for anemia management and adequacy. William McClellan, MD, lead author of the paper, said the work represented “a multidisciplinary collaboration with CMS to improve the dialysis care of adult hemodialysis patients that has been sustained over a substantial period of nearly 10 years.

“Non-government participants have donated their time to the design, implementation and oversight of the ESRD [Health Care Quality Improvement Program] HCQIP. We think that professionals in other fields of medicine should examine the lessons learned ... and apply these lessons to improving care for patients with other conditions.”