Dialysis Unplugged: The Medicare Quality Incentive Program: QIP or Quip?

Editorial – Dr. Ajay K. Singh

QIP denotes ‘”quality incentive program”, whereas a “Quip” may be defined as a joke or a witticism.

On November 2, 2011, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates Medicare policies and payment rates for 5,503 dialysis facilities paid under the End Stage Renal Disease (ESRD) Prospective Payment System (PPS) that was first implemented in calendar year (CY) 2011.

Here is where the quip is: “The final rule will also strengthen incentives for improved quality of care and better outcomes for beneficiaries diagnosed with ESRD through improvements to the ESRD Quality Incentive Program (QIP).“ 

The experience with ESAs has made it abundantly clear that in ESRD patients financial incentives are a powerful driver of clinical practice and quality improvement. Consequently, any changes to the “quality incentive program” or QIP could have profound effects on clinical practice and quality. With this as a background, surely you would agree with me that CMS has lost an opportunity or perhaps been lobbied in not taking advantage of an opportunity to incorporate harder quality endpoints in its QIP program.

I would give thumbs down to all except one of the six measures for PY 2014 (Table 1). The exception being the AV fistula measure, which seems sensible.

Now, I don’t come to this conclusion lightly, but as someone who is a member of CMS’s MEDCAC committee and a past member of the National Quality Forum steering committee for ESRD. I am well aware of the complexity of measure development and of selecting measures for incorporation into a QIP. Sadly, I am also all too aware of the complex balancing that often occurs in these measure development processes as direct industry input, indirect industry input (through “independent” professional societies), and the inputs of patient advocates are managed. It would be a stretch to say that the QIP as currently iterated is patient centric. Rather, the measures seem to be formulated to make providers and the payor - CMS here - look good.

What should have CMS done? At the very least it should have incorporated one or more measures that more closely associates with one or more hard patient outcomes. For example, rather than “Whether the facility administers a patient experience of care survey” it could have incorporated into the measure achieving some minimum score of quality of life for example: “percent of patient’s with a quality of life composite score in the top tertile of scores”. Similarly, a more thoughtful approach towards calcium and phosphorus management might have generated a measure along the lines of “percent of patient’s with a calcium x phosphorus product below 55”, rather than “whether the facility monitors phosphorus and calcium levels on a monthly basis.” Yes, its important that the facility monitors phosphorus and calcium levels on a monthly basis, but that said, CMS should have formulated the measure to associate, however imperfectly, with a patient outcome.

Here is an important insight from Dr. Jeff Berns, who participated in February 2011 as member of the National Quality for ESRD Steering Committee and writes:“ It is hard …to come up with evidence-based and meaningful quality metrics that can be applied across a wide spectrum of dialysis facilities and patients in this country and not have unintended consequences that might adversely and unfairly affect either patients or dialysis facilities. Nonetheless, it's hard to believe that we can't come up with some metrics at some point in time that address other aspects of care in dialysis patients (blood pressure, hypertension, hypotension, mineral and bone disease, transplantation referral, dialysis, access, use of home dialysis). We can come up with a whole list of issues at which we might want to look in the future as the QIP matures to better ensure that patients are getting the highest quality care they possibly can.”

Bottom line: I agree with Jeff: it's hard to believe that we can't come up with some metrics at some point in time that address other aspects of care in dialysis patients (blood pressure, hypertension, hypotension, mineral and bone disease, transplantation referral, dialysis, access, use of home dialysis). Come on CMS, lets do it right the first time.