Final Rule For ESRD Quality Incentive Program
The Centers for Medicare & Medicaid Services (CMS) issued Dec. 29, 2010 a final rule establishing performance standards for dialysis facilities and providing pay-for-performance adjustments to individual end-stage renal dialysis (ESRD) facilities. The ESRD Quality Incentive Program (QIP) is a companion piece to the ESRD Prospective Payment System (PPS), which is effective Jan. 1, 2011.
The ESRD QIP final rule establishes a scoring methodology CMS will use to assess each dialysis facility. The period of performance under which facilities first will be evaluated is payment year 2010, running from Jan. 1, 2010 through Dec. 31, 2010. The performance standard for each facility will be the lesser of the national average performance on the measure in 2008 or that facility’s performance on each measure during 2007.
ESRD facilities will be judged on how well their performance meets the standard for each of three measures established in the ESRD PPS final rule, issued July 26, 2010 and published in the Aug. 12, 2010 Federal Register. Two of the three measures assess whether patients’ hemoglobin levels are maintained in an acceptable range and the third measures the effectiveness of the dialysis treatment in removing waste from the patient’s blood.
The following are brief descriptions of the ESRD QIP measures and standards applying to facility performance that will determine reductions in 2012:
Anemia Management: The intent is to control anemia and maintain optimum hemoglobin levels within the range of 10-12 g/dL (grams per deciliter). Anemia management will be assessed by two separate measures:
- CMS will assess the percentage of patients whose hemoglobin levels dipped under 10 g/dL. The program assigns this measure the greatest weight in facility performance calculation, because numbers under 10 g/dL are highly undesirable. (Weight = 50 percent)
- CMS will assess the percentage of patients whose hemoglobin levels exceeded 12 g/dL. Numbers greater than 12 g/dL could suggest unnecessary or excessive administration of certain drugs. (Weight = 25 percent)
Hemodialysis Adequacy: The intent is to ensure adequate removal of waste products in the blood. CMS will assess the percentage of patients who achieve a urea reduction ratio (URR) of 65 percent or greater at each facility. (Weight = 25 percent)
Facilities that do not meet or exceed performance standards will be subject to a payment reduction up to 2 percent. ESRD QIP payment adjustments will apply to payments under the ESRD PPS for outpatient maintenance dialysis items and services furnished to Medicare patients by ESRD facilities between Jan. 1, 2012 and Dec. 31, 2012.
The maximum Total Performance Score a facility can achieve is 30 (10 points per measure). After ESRD facility scores and payment determinations are finalized, CMS will furnish each facility with a 2012 certificate noting the facility’s Total Performance Score and its score for each individual measure. Facilities are required to display their certificate where patients can see it.
Providers and facilities will be given the opportunity to review their scores and any resulting payment adjustments prior to CMS releasing the information publicly.