ESRD Quality Incentive Program: The first program of its kind in Medicare, the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) promotes high-quality outpatient care for patients with ESRD by linking a portion of each facility’s reimbursement for dialysis treatment directly to its performance on measures selected by the Centers for Medicare & Medicaid Services (CMS). Changes in reimbursement systems (via the ESRD Prospective Payment System) and an increased emphasis on patient outcomes (as embodied by CMS’s Value-Based Purchasing efforts) may result in unintended consequences for Medicare beneficiaries; for example, facilities may undertreat patients in order to maximize profits and minimize costs. The ESRD QIP helps guard against that possibility by evaluating the quality of care that dialysis facilities provide. The ESRD QIP reduces payments (by up to two percent) to facilities that do not meet or exceed certain performance standards, and the program communicates the results to the facilities themselves and the public at large.
The ESRD QIP includes clinical measures (which evaluate the quality of care provided by facilities) and reporting measures (which evaluate whether facilities collect and/or report data to CMS). These performance measures change from year to year. Currently, ESRD QIP measures address:
- Anemia Management
- Dialysis Adequacy
- Vascular Access
- Mineral Metabolism
- Patient Experience of Care
In addition, CMS is committed to improving the quality of care delivered to beneficiaries, as well as ensuring that access to care is not impeded—especially to racial and ethnic minorities, as well as other medically underserved populations. CMS closely monitors practice patterns as well as patient outcomes; if it discovers issues with regard to access, cost, or quality of care, then the facility involved will be thoroughly investigated, followed by appropriate and timely corrective action.
ESRD Quality Measures Development Program: The Quality Measurement and Health Assessment Group at CMS is responsible for the development, maintenance, and implementation of quality measures for dialysis facilities certified by Medicare. The group supports other CMS components in implementing these measures for value-based purchasing through the QIP, quality reporting, and public reporting through the Dialysis Facility Compare website. Measures developed and currently maintained address quality of care provided to dialysis patients in the areas of dialysis adequacy, anemia management, mineral bone disease, vascular access, hospitalizations, rehospitalizations, and mortality. Ongoing work is expanding these measures to assess quality as defined in the CMS Quality Strategy.
Conditions for Coverage Program: The Center for Clinical Standards and Quality’s (CCSQ) clinical standards group develops and maintains the ESRD conditions for coverage, the minimum health and safety requirements that dialysis facilities must meet in order to participate in Medicare. These conditions (found at 42 CFR Part 494) set requirements for infection control, water and dialysate quality, reuse of hemodialyzers and bloodlines, physical environment, patient’s rights, patient assessment, patient plan of care, care at home, quality assessment and performance improvement, special purpose dialysis facilities (for example, summer camps), laboratory services, personnel qualifications, responsibilities of the medical director, medical records, and governance. The group collaborates with fellow CMS and HHS components, as well as with external stakeholders, to ensure that these standards are up to date and effectively interpreted and applied.
Lauren E. Oviatt
Survey and Certification Program: The Survey and Certification Group of CMS is responsible for ensuring that all Medicare-certified ESRD facilities meet Federally-mandated standards, which are set to protect the health and safety of the ESRD patients. The standards include safety, clinical care, and infrastructure standards which are critical elements for the well-being of patients.
- Safety standards include: infection control practices; water treatment and dialysate preparation elements; reprocessing activities; and equipment/structural maintenance.
- Clinical standards include: review of the facility’s capacity to monitor, recognize, and address individual clinical care issues and the facility-wide quality assessment and performance improvement (QAPI) program. Patients’ rights are also reviewed.
- Infrastructure standards include: personnel qualifications; medical recording structure; the and governance structure
The survey process is conducted by specifically-trained health care professionals (based in State health departments) who conduct on-site facility reviews. These surveyors utilize national/facility data, national/community-based standards, patient/personnel interviews, observations of facility practices, and review of medical records to conduct their reviews. The surveyors follow-up on each survey by monitoring the appropriateness of corrective action plans and program improvements.
Dialysis Facility Compare: The Dialysis Facility Compare (DFC) contains information about Medicare certified dialysis facilities. Included is facility name and contact information, location, types of services provided, certification date, and quality measures for each facility. DFC allows patients, family members, healthcare providers, and stakeholders, to compare the quality of dialysis facilities across the country, and to access a variety of kidney disease and dialysis resources. DFC also includes demographic data, medical claims, payment, and entitlement data on patients with Medicare who have ESRD; and aggregate ESRD patient information.
Consolidated Renal Operations in a Web-Enabled Network (CROWNWeb) - CMS utilizes CROWNWeb data as one of the primary data sources for the Quality Measures (QM) Project, enabling ESRD stakeholders to gauge patient care outcomes by offering comparisons of clinical performance results at the facility, ESRD Network, and national levels. The database can quickly calculate and produce QM reports, allowing facilities to more closely monitor patient clinical measures and rapidly evaluate treatment trends to ensure patients receive the appropriate treatment. CROWNWeb data reporting of attestations are used to calculate facility Total Performance Scores as part of the Quality Incentive Program (QIP). Facilities are evaluated and scored based on their compliance with CMS-mandated reporting measurements. Using CROWNWeb (and other) data sources, scores are calculated for each facility, and score certificates must be published in a visible area in each facility.