Dial­y­sis pay-for-per­for­mance looms

Modern Healthcare - - NEWS - By Sabriya Rice

In an ef­fort to im­prove out­comes at the na­tion’s 6,000 dial­y­sis fa­cil­i­ties, Medi­care plans to cut re­im­burse­ment rates up to 2% if the fa­cil­i­ties per­form poorly on an ex­panded set of qual­ity met­rics.

De­spite push­back from providers on ex­ist­ing met­rics, used only to rate fa­cil­i­ties, a study high­lighted “a mas­sive fail” in achiev­ing high per­for­mance on at least one key met­ric con­sid­ered the stan­dard of care for more than 20 years. “It makes me think there’s some­thing wrong with the sys­tem,” said Dr. Mah­moud Malas, au­thor of a JAMA Surgery re­port on re­gional vari­a­tion in qual­ity for end-stage re­nal dis­ease care.

Re­searchers and pa­tient ad­vo­cates say a num­ber of sys­temic chal­lenges limit providers’ abil­ity to de­liver higher-qual­ity care to end-stage re­nal dis­ease (ESRD) pa­tients. They in­clude mis­aligned re­im­burse­ment in­cen­tives that still re­ward providers de­spite sub­stan­dard care and a fail­ure to ad­dress fac­tors that pre­vent pa­tients from fol­low­ing di­etary guide­lines or rou­tinely show­ing up for treat­ments.

“The big­gest con­cern for pa­tients is, ‘Can I work?’ and ‘Can I eat?’ ” said Lori Hartwell, a for­mer dial­y­sis pa­tient and founder of the not-for-profit pa­tient ad­vo­cacy group Re­nal Sup­port Net­work. “There is not enough ev­i­dence for mea­sures that could be truly mean­ing­ful from a pa­tient’s per­spec­tive.”

More broadly, there’s con­cern over the na­tion’s fail­ure to ad­dress is­sues that are fill­ing the pipeline with new dial­y­sis pa­tients, most of whom reach the end stage of chronic kid­ney dis­ease only af­ter years of poorly con­trolled hy­per­ten­sion and di­a­betes.

Poor co­or­di­na­tion be­tween pri­mary-care doc­tors, nephrol­o­gists and vas­cu­lar sur­geons of­ten leads to a fail­ure to de­tect early signs of kid­ney dis­ease, which would en­able providers to get pa­tients on a tra­jec­tory to avoid dial­y­sis. “It’s not one par­tic­u­lar spe­cialty,” said Malas, di­rec­tor of en­dovas­cu­lar surgery at the Johns Hop­kins Bayview Med­i­cal Cen­ter, Bal­ti­more. “We are all re­spon­si­ble for this fail­ure.”

Since the 1970s, Medi­care has paid the bill for treat­ing ESRD pa­tients. Nearly 489,000 pa­tients were in the agency’s ESRD pro­gram in 2010, ac­cord­ing to the U.S. Re­nal Data Sys­tem, at a cost of $32.9 bil­lion.

Pa­tients with re­nal fail­ure ex­pe­ri­ence a de­press­ing lifestyle change. With­out a trans­plant, pa­tients re­quire dial­y­sis to fil­ter tox­ins from their body three times a week for the rest of their lives. Each treat­ment lasts about four hours. Trans­planted kid­neys could end dial­y­sis, but only 17,105 kid­ney trans­plants oc­curred in the U.S. in 2014, ac­cord­ing to the Na­tional Kid­ney Foun­da­tion.

De­spite pay­ing an av­er­age of $88,000 an­nu­ally per pa­tient, the mor­tal­ity rate among dial­y­sis pa­tients is 7.4 times higher than the gen­eral pop­u­la­tion. The U.S. has one of the worst dial­y­sis sur­vival rates in the world. Ac­cord­ing to an anal­y­sis in the Jour­nal of the Amer­i­can So­ci­ety of Nephrol­ogy, 21.7% of U.S. dial­y­sis pa­tients die ev­ery year com­pared with 6.6% in Ja­pan and 15.6% in Europe.

To im­prove qual­ity in the pro­gram, the CMS last month pro­posed link­ing qual­ity scores on a suite of in­di­ca­tors to re­im­burse­ment. The rule, which will go into ef­fect Jan. 1, 2016, also said providers should an­tic­i­pate new met­rics be­ing added to the ESRD Qual­ity Im­prove­ment Pro­gram in fu­ture years. Com­ments on the pro­posed changes will be ac­cepted through Aug. 25.

Eleven mea­sures are cur­rently eval­u­ated in the qual­ity pro­gram. The eight clin­i­cal mea­sures in­clude us­ing the best vein ac­cess method (ar­te­ri­ove­nous fis­tula) in­stead of catheters; the ad­e­quacy of toxin fil­tra­tion dur­ing dial­y­sis, which is closely as­so­ci­ated with time in the clinic; in­fec­tion rates; ane­mia and cal­cium man­age­ment; and pa­tient ex­pe­ri­ence.

The CMS plans to add qual­ity-of-life mea­sures and read­mis­sion rates in 2018. In 2019, the CMS will add sea­sonal flu vac­ci­na­tion and ul­tra­fil­tra­tion rates. The lat­ter is a process that re­moves ex­cess wa­ter and sodium from the body.

Sev­eral of the pro­posed mea­sures have drawn fire from

kid­ney-care qual­ity re­searchers and providers. For in­stance, a draft re­port is­sued last month by the Re­nal Stand­ing Com­mit­tee of the not-for-profit Na­tional Qual­ity Fo­rum, which en­dorses con­sen­sus stan­dards for per­for­mance mea­sure­ment, re­jected the CMS’ pro­posal to in­clude ul­tra­fil­tra­tion as a met­ric. Although high ul­tra­fil­tra­tion rates are as­so­ci­ated with a greater risk of all-cause and car­dio­vas­cu­lar deaths, pa­tients “may be dy­ing not be­cause we are ul­tra-fil­ter­ing them more, but be­cause they have phys­i­olo­gies that make them more dan­ger­ous pa­tients,” said nephrol­o­gist Dr. Alan Kliger, chief qual­ity of­fi­cer for Yale New Haven (Conn.) Health Sys­tem.

The NQF also de­clined to rec­om­mend a met­ric that looks at pa­tients hav­ing too much cal­cium, a prob­lem as­so­ci­ated with high mor­tal­ity rates.

That lack of con­sen­sus over met­rics has led to ques­tions by some providers about how ef­fec­tive they are. A 2% re­duc­tion is a “sub­stan­tial is­sue all providers take se­ri­ously,” said Dr. Frank Mad­dux, chief med­i­cal of­fi­cer of Fre­se­nius Med­i­cal Care, one of the two largest U.S. dial­y­sis providers. If the mea­sures are not aligned with the state of the science, “then we aren’t spend­ing our time on those things that are most im­por­tant.”

The CMS says it has taken a “con­ser­va­tive ap­proach” in ap­ply­ing qual­ity mea­sures to pay­ment ad­just­ment.

While providers will raise their con­cerns dur­ing the com­ment pe­riod, there’s con­cern over the dial­y­sis in­dus­try’s fail­ure to pro­vide the stan­dard of care on long-es­tab­lished met­rics closely as­so­ci­ated with bet­ter out­comes.

Malas’ study in JAMA Surgery last month noted that many kid­ney-fail­ure pa­tients con­tinue to re­ceive crit­i­cal dial­y­sis treat­ments through catheters, a vein ac­cess method widely known to in­crease in­fec­tion risk, blood clots and death. Fis­tu­las, the pre­ferred method, are not used in a quar­ter of the na­tion’s dial­y­sis pa­tients, ac­cord­ing to es­ti­mates. Each hos­pi­tal­iza­tion for catheter-re­lated in­fec­tions costs an av­er­age of $23,000. Re­duc­ing catheter use by half could yield $1 bil­lion a year in Medi­care sav­ings, ac­cord­ing to a 2011 ar­ti­cle in the Jour­nal of the Amer­i­can So­ci­ety of Nephrol­ogy.

“It’s both sur­pris­ing and dis­ap­point­ing,” Malas said. “We know fis­tula use is as­so­ci­ated with the best out­comes.”

The CMS be­gan pub­licly rat­ing dial­y­sis providers based on per­for­mance on the avail­able met­rics us­ing a fives­tar sys­tem rolled out in Jan­uary. Trans­parency is a great step for­ward, said Hartwell, who was on dial­y­sis for 13 years be­fore re­ceiv­ing a kid­ney trans­plant.

Pa­tient ad­vo­cates are most con­cerned about is­sues that drive peo­ple away from the clin­ics. “You can have a ton of mea­sures, but the real key is to strike a good bal­ance for what is mean­ing­ful for pa­tients,” Hartwell said. “Once the com­mu­nity starts to look at that, they’ll un­der­stand why pa­tients want to shorten their treat­ments or don’t want to show up.”

While providers will raise their con­cerns dur­ing the com­ment pe­riod, there’s con­cern over the dial­y­sis in­dus­try’s fail­ure to pro­vide the stan­dard of care on long-es­tab­lished met­rics closely as­so­ci­ated with bet­ter out­comes.

GETTY IM­AGES

The U.S. has one of the

worst dial­y­sis sur­vival

rates in the world.

Ac­cord­ing to an anal­y­sis in

the Jour­nal of the Amer­i­can

So­ci­ety of Nephrol­ogy,

21.7% of U.S. dial­y­sis

pa­tients die ev­ery year

com­pared with 6.6% in

Ja­pan and 15.6% in Europe.

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