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ESRD Quality Monitoring Initiative

October 7, 2010 in Medicare, P4P, Quality, Uncategorized | No comments

All patients with end stage renal disease (ESRD) are eligible for Medicare regardless of their age.  In 1972, the Social Security Act extended all Medicare Part A and Part B benefits to individuals with ESRD (of any age) who are entitled to receive Social Security benefits. ESRD beneficiaries now account for 1% of Medicare enrollment. This post review the types of services ESRD Medicare beneficiaries receive and how Medicare pays providers for these services.  Today, however, I will review Medicare efforts to improve the quality of care ESRD beneficiaries receive.  You can find an overview of the ESRD Quality Improvement Program (QIP) here.

Timeline

• 1972. the Social Security Act extends all Medicare Part A and Part B benefits to individuals with ESRD (of any age) who are entitled to receive Social Security benefits. ESRD beneficiaries account for 1% of Medicare enrollment.
• 1978. ESRD Amendments require the formation of ESRD Network Organizations to support the ESRD program. CMS currently contracts with 18 ESRD networks.
• 1994. The Core Indicators Project was established to improve the care of patients with ESRD.  The Core Indicators included measures related to anemia management, adequacy of hemodialysis, nutritional status and blood pressure control
• 1999 (Mar). ESRD CIP was merged with the ESRD Clinical Performance Measures.
• 2000 (Jan). Section 4558(b) of the Balanced Budget Act of 1997 required CMS to develop and implement a method to measure and report
  the quality of renal dialysis services furnished under the Medicare program. To implement this legislation, CMS developed the ESRD Clinical Performance Measures (CPM) Project based on the National Kidney Foundation’s Dialysis Outcome Quality Initiative (NKF–DOQI) Clinical Practice Guidelines.
• 2001 (Jan). Medicare launched Dialysis Facility Compare based on the Nursing Home Compare website. The quality measures initially reported on DFC were measures of anemia control, adequacy of hemodialysis treatment and patient survival. Medicare claims data were used to calculate the anemia management and hemodialysis
  adequacy rates, and administrative data were used to determine patient survival rates.
• 2008 (Apr). The updated ESRD Conditions for Coverage final rule, which contains revised requirements that dialysis providers and facilities must meet in order to be approved by Medicare and receive payment. As part of the revised requirements, dialysis providers and facilities are each required to implement their own quality assessment and performance improvement program. The CPMs were updated to include 26 measures from the areas of anemia management; hemodialysis adequacy; peritoneal dialysis adequacy; mineral metabolism; vascular access; patient education/perception of care/quality of life; and patient survival.
• 2008 (Jul). Section 153(c) of the Medicare Improvements for Patients and Providers Act (MIPPA) requires that Medicare implement a quality incentive program (QIP)
• 2009 (Feb). Medicare began implementing the CROWNWeb system to electronically collect information on about patients, facilities, providers, and clinical data to support the CPM Project.
• 2009 (Sep). Medicare decides to begin paying ESRD providers based on a prospective payment system (PPS) beginning in 2011.

Where are we now?  Medicare will begin paying dialysis providers through a PPS beginning in 2011.  This will give providers an incentive to provider services more cost effectively, but also potentially will give them an incentive to decrease the quality of care.  To ensure that ESRD beneficiaries receive the same quality of services under PPS as under a FFS, Medicare developed the QIP.  Below, I review the QIP in more detail.

Quality Incentive Program (QIP)

The QIP requires Medicare to establish an ESRD quality program using the following steps:

1. Select measures;
2. Establish the performance standards that apply to the individual measures;
3. Specify a performance period with respect to a year;
4. Develop a methodology for assessing the total performance of each provider and facility based on the performance standards with respect to the measures for a performance period; and
5. Apply an appropriate payment reduction to providers and facilities that do not meet or exceed the established total performance score.

Medicare has already chose quality measures for the initial year.  Data from the following three measures will be submitted to CMS via ESRD claims.

• Percentage of Medicare patients with an average Hemoglobin <10.0 g/dL (2%);
• Percentage of Medicare patients with an average Hemoglobin >12.0 g/dL (26%); and
• Percentage of Medicare patients with an average Urea Reduction Ratio (URR) >65 percent (96%).

The numbers in parentheses represent the national performance rates for all dialysis providers and facilities based on 2008 data from the Dialysis Compare website.  Providers receive a score between 0-10 based on their performance on each measure.  Medicare has recently proposed a scoring method which subtracts 2 points for every 1 percentage point the provider falls below the initial performance standard (e.g., if the initial performance standard for a particular provider or facility for the Hemoglobin>12 g/dL is set as the 2008 national average rate (26%), then if that provider/facility had 28% of Medicare patients with hemoglobin levels>12 g/dL during 2010, the provider/facility would receive 6 points for its performance on the measure as 28% is 2 percentage points below the performance standard). The provider’s total score could be weighted evenly across all three scores.  Alternatively, some have proposed weighting the Hemoglobin <10.0 g/dL at 50% of the score and the other two quality measures at 25% of the provider’s score to put more weight on avoiding low hemoglobin levels.

Payment will be based on the provider’s score.  THe proposed payment reduction scale is as follows:

• 26-30 points: 0.0%
• 21-25 points: -0.5%
• 16-20 points: -1.0%
• 11-15 points: -1.5%
• 0-10 points: -2.0%

In the future, Medicare will consider expanding the QIP program to include additional measures.  Quality measures considered include:  Kt/V, vascular access rates, bone and mineral metabolism, and access infection rates.

Source:

• Federal Register42 CFR Part 413 “Medicare Program; End-Stage Renal Disease Quality Incentive Program” Vol. 75, No 155, Thursday, August 12, 2010, Proposed Rules, pp. 49215-49232.

Tags: Dialysis, ESRD, P4P, VBP

ESRD P4P

Summary

In February 2009, the American Recovery and Reinvestment Act of 2009 (Recovery Act) initially provided states and the District of Columbia (the District) with an estimated $87 billion in increased Medicaid funds through December 2010, provided they met certain requirements. Funds were made available to states and the District through an increase in the Federal Medical Assistance Percentage (FMAP), the rate at which the federal government matches state expenditures for most Medicaid services. In March 2010, Congress passed the Patient Protection and Affordable Care Act (PPACA), which prohibits states from adopting certain changes to program eligibility in order to receive federal reimbursement, and in August 2010, extended increased FMAP rates through June 2011. GAO was asked to examine issues related to Medicaid funds under the Recovery Act. GAO examined (1) states’ and the District’s access to and use of increased FMAP funds, and (2) states’ and the District’s plans to sustain their Medicaid programs once these funds are no longer available. To do this work, GAO surveyed state Medicaid officials in the 50 states and the District in August 2009 and March 2010 about their program enrollment, uses of funds, program adjustments, and program sustainability. GAO obtained responses from all states and the District. GAO also reviewed CMS data and guidance and interviewed CMS and state officials.

States and the District are on pace to draw down about 94 percent—$82 billion of the estimated $87 billion—in increased FMAP funds provided by the Recovery Act. Most states adjusted their Medicaid programs to comply with the act’s requirements, and nearly all states and the District reported using the increased FMAP to cover increased enrollment, which grew by 14.2 percent nationally between October 2007 and February 2010. Enrollment growth across the states and the District ranged from about 1 percent to 38 percent, with 22 states and the District experiencing a 10 to less than 20 percent increase. Although most enrollment growth was attributable to children, the highest growth rate was among the non-disabled, non-aged adult population. Forty-seven states and the District reported concern regarding the sustainability of their Medicaid programs without the increased FMAP, and 46 states took steps to address sustainability, including introducing financing arrangements, such as taxes on health care providers, or reducing provider payments. Most states and the District also reported proposed changes for the future. Congress passed legislation in August 2010 to extend the increased FMAP through June 2011, although at lower rates than provided by the Recovery Act. How the subsequent return to regular FMAP rates will affect states and the District will vary depending on their unique economic circumstances. GAO estimates that regular FMAP rates will be, on average, nearly 11 percentage points lower than increased FMAP rates available in December 2010. For future adjustments, states and the District will need to consider PPACA, which prohibits more restrictive eligibility standards, methods, or procedures until 2014, in order to receive federal Medicaid reimbursement. HHS provided technical comments to this report, which GAO incorporated as appropriate.

Featured Story, Sept. 28, 2010 

CIGNA Partners with Physicians Group to Launch Accountable Care Organization in Atlanta

Reprinted from HEALTH PLAN WEEK, the industry’s leading source of business, financial and regulatory news of health plans, PPOs and POS plans.

By Stephanie Woodrow, Contributing Editor (swoodrow@aishealth.com)

CIGNA Corp. announced that it has partnered with Piedmont Physicians Group to launch an accountable care organization (ACO) pilot program in the Atlanta area. Piedmont Physicians Group is part of Atlanta-based Piedmont Health Care, an integrated delivery system.

The health plan operator has multipayer pilots in Colorado, New Hampshire, Pennsylvania and Vermont, as well as CIGNA-only ACO pilots in Connecticut, New Hampshire and Texas, according to CIGNA spokesperson Amy Turkington. Last October, the company established a similar ACO arrangement with Georgia-based ProHealth Physicians, Inc. Results from the existing pilots are not available.

The Piedmont pilot, which went into effect July 1, will focus on approximately 10,000 CIGNA members who receive care from one of 100 primary care physicians who are part of Piedmont’s network. During the first 12 months of the pilot, the physician group will monitor and coordinate patient care, with patients taking on no additional responsibility. CIGNA, which will evaluate the results after one year, expects patients who need assistance managing chronic conditions to see the most immediate benefit.

Under the agreement, CIGNA will pay primary care physicians their usual fee. In addition, doctors will receive a fee for care coordination and other medical home services and will be eligible to earn performance bonuses if they meet targets for improving quality and lowering costs.

Although CIGNA’s efforts to improve care while reducing costs are “a good thing,” it’s not exactly an ACO, according to Joe Gifford, M.D., senior medical director with Blues plan operator the Regence Group.

“The phrase ‘ACO’ is becoming a word that can mean almost anything — in this case [of CIGNA’s partnership with Piedmont Physicians Group] a complex case management arrangement with a large primary care provider group,” he tells HPW. Gifford adds of the partnership, “it’s a stretch of the term ACO, but if you called it a medical home for the medically complex patients then that’s a good description.” During a July 21 webinar on ACOs sponsored by AIS, Gifford contended that ACOs should make provider groups accountable for squeezing costs out of the system, rather than only improving quality.

It’s unclear whether ACOs are successful, mainly because success has yet to be defined, according to Gifford. However, “We think this is an important step in redefining how health care is reimbursed,” he says, adding that CIGNA’s efforts are a “solid first step” toward the goals of ACOs.

CIGNA representatives did not respond to a request for data about the success of their other pilot programs.

“The jury’s still out” on whether ACOs are lowering costs while improving care, Gifford cautions.

 

Piedmont taking over…

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