ESRD Prospective Payment System Research Articles

Effect of ESRD Prospective Payment System on Utilization of Peritoneal Dialysis in Patients with Kidney Allograft Failure

Effect of ESRD Prospective Payment System on Utilization of Peritoneal Dialysis in Patients with Kidney Allograft Failure

The US Supreme Court and Future of Financing Dialysis Care.

The US Supreme Court and Future of Financing Dialysis Care.

Variability in Cinacalcet Prescription across US Hemodialysis Facilities.

Calcimimetic drugs used to treat secondary hyperparathyroidism are being considered for inclusion in the Medicare ESRD Prospective Payment System bundle after an evaluation period. Understanding of utilization patterns of calcimimetics across dialysis facilities may help align financial incentives with clinical objectives. Our study's purpose was to describe the distribution of cinacalcet prescription across United States hemodialysis facilities and to explore factors that may influence cinacalcet utilization. We used monthly cross-sectional data from the Dialysis Outcomes and Practice Patterns Study in 2014 to characterize the distribution of cinacalcet prescription across 203 United States hemodialysis facilities (10,521 patients). On the basis of associations with parathyroid hormone levels from patient-level analyses, we used linear mixed-effects regressions to estimate the associations between three facility-level exposures (black race, <65 years old, and having ≥3 years on dialysis [vintage]) and the prevalence of cinacalcet prescription, adjusting for facility- and patient-level potential confounders. The mean percentage of patients in each facility with cinacalcet prescription was 23% in June 2014 (median, 22%; interquartile range, 13%-30%). Adjusted for facility-level and nonexposure patient-level variables, the difference in prevalence of cinacalcet prescription between facilities with the highest and lowest quartiles of percentage of black patients was 7.8% (95% confidence interval [95% CI], 0.8% to 14.8%; P for trend =0.03). The adjusted prevalence difference was 7.3% for the percentage of patients aged <65 years (95% CI, -0.1% to 14.7%; P for trend =0.06) and 11.9% for the percentage of patients with ≥3 years of dialysis (95% CI, 2.4% to 21.4%; P for trend =0.02). These associations changed appreciably, becoming much weaker or even reversing, after further adjusting for the patient-level exposure variables. Facilities treating more patients who are black, under age 65 years, and having dialysis vintage ≥3 years have higher average levels of cinacalcet prescription. However, these differences were strongly attenuated after accounting for the unbalanced distributions of these patient case-mix variables.

Home Dialysis in the Prospective Payment System Era

The ESRD Prospective Payment System introduced two incentives to increase home dialysis use: bundling injectable medications into a single payment for treatment and paying for home dialysis training. We evaluated the effects of the ESRD Prospective Payment System on home dialysis use by patients starting dialysis in the United States from January 1, 2006 to August 31, 2013. We analyzed data on dialysis modality, insurance type, and comorbidities from the United States Renal Data System. We estimated the effect of the policy on home dialysis use with multivariable logistic regression and compared the effect on Medicare Parts A/B beneficiaries with the effect on patients with other types of insurance. The ESRD Prospective Payment System associated with a 5.0% (95% confidence interval [95% CI], 4.0% to 6.0%) increase in home dialysis use by the end of the study period. Home dialysis use increased by 5.8% (95% CI, 4.3% to 6.9%) among Medicare beneficiaries and 4.1% (95% CI, 2.3% to 5.4%) among patients covered by other forms of health insurance. The difference between these groups was not statistically significant (1.8%; 95% CI, -0.2% to 3.8%). Conversely, in both populations, the training add-on did not associate with increases in home dialysis use beyond the effect of the policy. The ESRD Prospective Payment System bundling, but not the training add-on, associated with substantial increases in home dialysis, which were identical for both Medicare and non-Medicare patients. These spill-over effects suggest that major payment changes in Medicare can affect all patients with ESRD.

The ESRD Quality Incentive Program-Can We Bridge the Chasm?

The ESRD Quality Incentive Program (QIP) is the first mandatory federal pay for performance program launched on January 1, 2012. The QIP is tied to the ESRD prospective payment system and mandated by the Medicare Improvements for Patients and Providers Act of 2008, which directed the Centers for Medicare and Medicaid Services to expand the payment bundle for renal dialysis services and legislated that payment be tied to quality measures. The QIP links 2% of the payment that a dialysis facility receives for Medicare patients on dialysis to the facility's performance on quality of care measures. Quality measures are evaluated annually for inclusion on the basis of importance, validity, and performance gap. Other quality assessment programs overlap with the QIP; all have substantial effects on provision of care as clinicians, patients, regulators, and dialysis organizations scramble to keep up with the frequent release of wide-ranging regulations. In this review, we provide an overview of quality assessment and quality measures, focusing on the ESRD QIP, its effect on care, and its potential future directions. We conclude that a patient-centered, individualized, and parsimonious approach to quality assessment needs to be maintained to allow the nephrology community to further bridge the quality chasm in dialysis care.

Has dialysis payment reform led to initial racial disparities in anemia and mineral metabolism management?

Implementation of the Medicare ESRD prospective payment system (PPS) and changes to dosing guidelines for erythropoiesis-stimulating agents (ESAs) in 2011 appear to have influenced use of injectable medications among dialysis patients. Given historically higher ESA and vitamin D use among black patients, we assessed the effect of these policy changes on racial disparities in the management of anemia and mineral metabolism. Analyses used cross-sectional monthly cohorts for a period-prevalent sample of 7384 maintenance hemodialysis patients at 132 facilities from the Dialysis Outcomes and Practice Patterns Study (DOPPS) Practice Monitor. Linear splines with knots at each policy change were used in survey-weighted regressions to estimate time trends in hemoglobin (Hgb), erythropoietin (EPO) dose, intravenous (IV) iron dose, ferritin, transferrin saturation (TSAT) concentration, parathyroid hormone (PTH), IV vitamin D dose, cinacalcet use, and phosphate binder use. From August 2010 to December 2011, mean Hgb declined from 11.5 to 11.0 g/dl (P<0.001), mean EPO dose declined from 20,506 to 14,777 U/wk (P<0.001), and mean serum PTH increased from 340 to 435 pg/ml (P<0.001). No meaningful differences by race were observed regarding the rates of change of management practices or laboratory measures (all P>0.21). Mean EPO and vitamin D dose and serum PTH levels remained higher in blacks. Despite evidence that anemia and mineral metabolism management practices have changed significantly over time, there was no immediate indication of racial disparities resulting from implementation of the PPS or ESA label change. Further studies are needed to examine effects among patient and facility subgroups.

Guiding Principles and Checklist for Population-Based Quality Metrics

The Centers for Medicare and Medicaid Services oversees the ESRD Quality Incentive Program to ensure that the highest quality of health care is provided by outpatient dialysis facilities that treat patients with ESRD. To that end, Centers for Medicare and Medicaid Services uses clinical performance measures to evaluate quality of care under a pay-for-performance or value-based purchasing model. Now more than ever, the ESRD therapeutic area serves as the vanguard of health care delivery. By translating medical evidence into clinical performance measures, the ESRD Prospective Payment System became the first disease-specific sector using the pay-for-performance model. A major challenge for the creation and implementation of clinical performance measures is the adjustments that are necessary to transition from taking care of individual patients to managing the care of patient populations. The National Quality Forum and others have developed effective and appropriate population-based clinical performance measures quality metrics that can be aggregated at the physician, hospital, dialysis facility, nursing home, or surgery center level. Clinical performance measures considered for endorsement by the National Quality Forum are evaluated using five key criteria: evidence, performance gap, and priority (impact); reliability; validity; feasibility; and usability and use. We have developed a checklist of special considerations for clinical performance measure development according to these National Quality Forum criteria. Although the checklist is focused on ESRD, it could also have broad application to chronic disease states, where health care delivery organizations seek to enhance quality, safety, and efficiency of their services. Clinical performance measures are likely to become the norm for tracking performance for health care insurers. Thus, it is critical that the methodologies used to develop such metrics serve the payer and the provider and most importantly, reflect what represents the best care to improve patient outcomes.

Toward Population Management in an Integrated Care Model

Under the Patient Protection and Affordable Care Act of 2010, accountable care organizations (ACOs) will be the primary mechanism for achieving the dual goals of high-quality patient care at managed per capita costs. To achieve these goals in the newly emerging health care environment, the nephrology community must plan for and direct integrated delivery and coordination of renal care, focusing on population management. Even though the ESRD patient population is a complex group with comorbid conditions that may confound integration of care, the nephrology community has unique experience providing integrated care through ACO-like programs. Specifically, the recent ESRD Management Demonstration Project sponsored by the Centers for Medicare & Medicaid Services and the current ESRD Prospective Payment System with it Quality Incentive Program have demonstrated that integrated delivery of renal care can be accomplished in a manner that provides improved clinical outcomes with some financial margin of savings. Moving forward, integrated renal care will probably be linked to provider performance and quality outcomes measures, and clinical integration initiatives will share several common elements, namely performance-based payment models, coordination of communication via health care information technology, and development of best practices for care coordination and resource utilization. Integration initiatives must be designed to be measured and evaluated, and, consistent with principles of continuous quality improvement, each initiative will provide for iterative improvements of the initiative.

ASN End-Stage Renal Disease Task Force

For the first time in nearly 30 years, the Centers for Medicare and Medicaid Services (CMS) will implement a new payment system for dialysis patients. Since 1983, Medicare has reimbursed each dialysis session with a prospective payment—known as the composite rate—designed to cover the cost of center or home dialysis.1 Since implementation of the composite rate, however, new therapies—including erythropoietin, vitamin D, and iron—have emerged as new additional costs for standard dialysis care. These therapies are reimbursed separately from the composite rate and now compose approximately 40% of the total Medicare payment for each dialysis treatment.2 To improve the efficiency and flexibility of the ESRD Program, the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 mandated implementation of a comprehensive, case mix–adjusted, bundled-rate payment system for ESRD that includes therapies currently reimbursed outside the composite rate.3 The ESRD Prospective Payment System will be phased in on January 1, 2011, and fully implemented by 2014. Although MIPPA outlines the basic approach to bundling, the legislation grants CMS authority to finalize the components of the bundle and generate a detailed implementation plan. In September 2009, CMS released for public comment a proposed rule on ESRD bundling and is expected to issue a final rule on ESRD bundling in 2010. In addition, CMS is projected to release a proposed rule on a quality improvement program for ESRD care. Given the monumental significance of the new payment system, the American Society of Nephrology (ASN) formed an ESRD task force to assess and respond comprehensively to the proposed rule changes. Eight ASN members from diverse specialties and practice settings served on this task force, including early-career and established nephrologists as well as ASN policy staff. ASN's foremost concerns relate to preservation of patient access to optimal dialysis care and related …