Reporting Hospitalization for ESRD Patients - Why the delay?

The final rule for ESRD payment was published a few days ago. The document is difficult to read but one of the more interesting discussions in the document (page 173 onwards) is about CMS's dilemma on whether to introduce the standardized hospitalization ratio (SHR) as a QIP measure.  

CMS states: "Hospitalizations are an important indicator of patient quality of life and morbidity. The SHR is an NQF-endorsed (#1463), risk-adjusted measure of hospitalization for dialysis patients. The measure is claims-based and describes, as a ratio, the number of ESRD Medicare patient actual admissions versus expected hospitalizations adjusted for the facility’s Medicare patient case mix."

"We originally proposed to adopt the SHR measure for the PY 2014 ESRD QIP, but did not finalize the proposal, in part, because commenters voiced concerns regarding the accuracy of the co-morbidity data used in the calculation of the measures....”

“Although most commenters agreed that measures for hospitalization are important for quality reporting purposes, many commenters strongly opposed that the SHR measure be included in the ESRD QIP in subsequent payment years. “

“These commenters argued that the SHR measure is a measure over which facilities have little control because patients often follow the advice of their primary care physician or visit a hospital without consulting the facility to receive treatments that could be furnished in the outpatient setting.”

“Commenters expressed concern that the measure could lead to cherry-picking, disincentivize appropriate hospitalization, and is not transparent enough for facilities to make improvements in this area because of they are confused about the risk-adjustment methodology. “

“Other commenters stated that the measure needs further refinement and validation, specifically regarding risk adjustment for frail patients such as those in nursing homes, cultural factors, socioeconomic factors, and health factors specific to the ESRD population. “

CMS …"We intend to begin public reporting of the SHR on DFC [The Dialysis Facility Compare can be found at the DFC Web page on the Medicare.gov website at www.Medicare.gov/Dialysis] as of January 2013 to indicate the relative performance of facilities. We believe that dialysis facilities own partial responsibility for the rate at which their patients are hospitalized, in particular when that rate is substantially higher than at other peer facilities and may not be explained by variation in the illness of patients."

My take: strongly agree...but why the delay in introducing the SHR? A quote from Hamlet: "I do believe you think what now you speak; But what we do determine oft we break."