Abstract
BackgroundWe examined the association of dialysis facility characteristics with payment reductions and change in clinical performance measures during the first year of the United States Centers for Medicare & Medicaid Services (CMS) End Stage Renal Disease Quality Incentive Plan (ESRD QIP) to determine its potential impact on quality and disparities in dialysis care.MethodsWe linked the 2012 ESRD QIP Facility Performance File to the 2007–2011 American Community Survey by zip code and dichotomized the QIP total performance scores—derived from percent of patients with urea reduction rate > 65, hemoglobin < 10 g/dL, and hemoglobin > 12 g/dL—as ‘any’ versus ‘no’ payment reduction. We characterized associations between payment reduction and dialysis facility characteristics and neighborhood demographics, and examined changes in facility outcomes between 2007 and 2010.ResultsIn multivariable analysis, facilities with any payment reduction were more likely to have longer operation (OR 1.03 per year), a medium or large number of stations (OR 1.31 and OR 1.42, respectively), and a larger proportion of African Americans (OR 1.25, highest versus lowest quartile), all p < 0.05. Most improvement in clinical performance was due to reduced overtreatment of anemia, a decline in the percentage of patients with hemoglobin ≥ 12 g/dL; for-profits and facilities in African American neighborhoods had the greatest reduction.ConclusionsIn the first year of CMS pay-for-performance, most clinical improvement was due to reduced overtreatment of anemia. Facilities in African American neighborhoods were more likely to receive a payment reduction, despite their large decline in anemia overtreatment.
Highlights
We examined the association of dialysis facility characteristics with payment reductions and change in clinical performance measures during the first year of the United States Centers for Medicare & Medicaid Services (CMS) End Stage Renal Disease Quality Incentive Plan (ESRD Quality incentive plan (QIP)) to determine its potential impact on quality and disparities in dialysis care
First we explored what dialysis facility and neighborhood characteristics are associated with total performance scores that led to payment reductions under QIP
Facilities were located in neighborhoods that were 18.2% African American, though this distribution was right skewed; mean proportion African American was less than 1% in Quartile 1 and 54% in Quartile 4
Summary
We examined the association of dialysis facility characteristics with payment reductions and change in clinical performance measures during the first year of the United States Centers for Medicare & Medicaid Services (CMS) End Stage Renal Disease Quality Incentive Plan (ESRD QIP) to determine its potential impact on quality and disparities in dialysis care. In 2012, the United States Centers for Medicare and Medicaid Services (CMS) reported outcomes for its End-Stage Renal Disease Quality Incentive Program (ESRD QIP), a pay-for-performance (P4P) program for dialysis facilities. The ESRD QIP is instructive as a casestudy of the ability of financial incentives to improve quality and impact disparities, and the challenges of creating policy in changing clinical and policy contexts. Improvements for Patients and Provider Act of 2008 (MIPPA) which established the ESRD QIP, a value-based purchasing or P4P program for Medicare that began in 2012 [1]. MIPPA bundled payments to dialysis facilities starting in 2011 to reduce incentives to provide expensive erythropoietin stimulating agents (ESAs) due to high ESA costs and evidence of potential harms of ESAs at high doses [2,3,4,5]
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