Measuring and Incentivizing Quality:
An ESRD Quality Incentive Blueprint

The Kidney Care Quality Initiative
To assist policymakers, Kidney Care Partners (KCP) formed the Kidney Care Quality Initiative (KCQI) to develop a well-designed continuous quality improvement program that meets the needs of patients, other members of the kidney care community, and federal policymakers. The KCQI has developed a program that includes clinical and quality of life measures and allows for immediate implementation. 

ESRD Is Unique within the Medicare Community 
The Medicare ESRD Program is unique because it is the only Medicare program that cares for patients at the onset of their disease; dialysis providers were the first Medicare providers to be paid under a prospective payment system and the only Medicare providers that do not have an annual update mechanism prescribed in statute; and dialysis facilities have consistently reported quality data to CMS and demonstrated consistent improvement in the quality of the care they provide to patients.

KEY ASPECTS OF AN ESRD CONTINUOUS QUALITY IMPROVEMENT PROGRAM

Applicability. Independent dialysis facilities, hospital-based dialysis providers, and physicians should participate in any ESRD quality incentive program. They should be required to report quality data, based upon clinical and quality of life measures developed in consultation with the kidney care community, and receive quality bonus payments as incentives for continuous quality improvement based upon the attainment of benchmarks, as well as improvement. Pediatric facilities and physicians should participate in this quality incentive program, but because of the lack of evidence-based measures available, their inclusion should be phased-in during a 3-year period.

Rewarding Quality. Payments should be based on a composite score and awarded using a quintile scale that rewards attainment as well as improvement.  Low-performers should receive technical assistance to help them improve their performance. For example, if one percent of the update is put in a bonus pool for facilities, the facilities in the lowest quintile would receive a zero or de minis payments. Facilities in the highest quintile would receive the equivalent of a 1.7 percent increase in the composite rate.

Funding Quality Bonus Payments. Consistent with the treatment of other Medicare providers, quality bonus payments for the kidney care community should be funded by designating a portion of the annual update. Thus, as a first step, Congress should implement an annual update mechanism for dialysis facilities and fix the physician fee schedule to allow for updates. Once updates are in place, payments should be made for reporting during the first year to ensure consistent reporting across facilities and to allow for the development of appropriate information technology systems.

Measuring Quality. With the help of the kidney care community, CMS should identify a starter set of clinical and quality of life measures based upon an expanded set of the Clinical Performance Measures. In addition, Congress should establish an ESRD Advisory Committee comprised of patients and other members of the kidney care community to allow for the evolution of quality measures over time.