CMS Financial Penalties Not Leading to Dialysis Care Quality Improvements

(Reuters Health) – Financial penalties instituted by the Centers for Medicare and Medicaid Services (CMS) do not appear to have led to improved dialysis care, a new study suggests.

The analysis of data from more than 1,100 U.S. dialysis centers found that their total performance scores did not improve after being penalized under the CMS pay-for-performance program, which deducts up to 2% in annual Medicare reimbursement if total performance scores fall below a quality threshold, according to the report published in the Annals of Internal Medicine.

“Our study suggests that performance-based financial penalties under the ESRD QIP (End-Stage Renal Disease Quality Incentive Program) were not associated with improvement in the quality of care provided at outpatient dialysis centers in the United States,” said the study’s lead author, Dr. Kyle Sheetz, chief resident in general surgery at the University of Michigan/Michigan Medicine, in Ann Arbor.

There may be ways CMS could make its program more effective, Dr. Sheetz said in an email.

“Based on our study there are a couple things Medicare could consider and even change within the scope of regulations rather than statute,” Dr. Sheetz said. “For example, the quality measures change often. This may not allow centers, particularly those with limited resources, to plan ahead and make real changes. Committing to a certain set of outcomes for longer periods of time might help.”

Another possibility would be to increase financial penalties, Dr. Sheetz said. “Surely more money at risk would increase the incentives for some centers to improve their performance,” he added. “However, there are likely to be tradeoffs worth mentioning.”

“For example,” Dr. Sheetz said, “increasing the penalties to ensure better outcomes assumes that the outcome measures reflect ‘true’ quality appreciated by patients. If the measures aren’t reliable, we risk penalization for no gain. Perhaps more important is the impact on disparities. We know that dialysis centers that care for patients with low socioeconomic status, for example, are more likely to get penalized under the program. In this case, larger financial penalties may further disadvantage centers that care for the most marginalized patients.”

To take a closer look at the effect of the CMS penalties, Dr. Sheetz and his colleagues analyzed the impact of penalties levied in 2017 (based on performance in the calendar year 2015) on a dialysis center’s performance in 2017 and 2018.

The ESRD QIP scores in 2015, 2017 and 2018 included factors such as catheter utilization rate, KtV dialysis rate, NHSN blood stream infections, standardized readmission ratio, hypercalcemia, and anemic management. Scoring ranged from 0 to 100, with scores less than 60 incurring a penalty.

Out of 5,830 outpatient dialysis centers, 1,109 (19%) received penalties in 2017. Among the penalized centers 931 (84%) were chain-affiliated as compared to 4,418 (93.6%) of the non-penalized centers. A similar proportion of penalized and non-penalized centers were for-profit businesses. A slightly higher percentage of penalized centers (36.4%) were located in ZIP codes with a higher average proportion of non-white minority patients compared with non-penalized centers (31.2%). The median annual income at the ZIP code level was also slightly lower for penalized centers compared with non-penalized centers ($49,290 versus $51,686).

The researchers found that penalties incurred in 2017 were not associated with improvement in dialysis centers’ total performance scores in 2017 (0.4 points) or 2018 (0.3 points). There was also no association between penalization and improvement in specific measures.

The new article “is really interesting,” said Julius Chen, an assistant professor of health policy and management at Columbia University’s Mailman School of Public Health in New York City. “There’s so much interest now in what works and what doesn’t. I think CMS has invested a lot in quality-based payments. And I think the overall intention is good. The challenge is in how these models are structured.”

Things may improve over time, Chen said. “What will probably happen with this is continued refinements in the way quality metrics and incentives are defined,” he added. “The first thing that comes to mind is, is the penalty large enough? Also, how easy is it for providers to engage in these improvement efforts.”

One problem currently is that there “is a wide scope of priorities that change quite often,” Chen said. “That’s challenging for providers. And is one or two years enough time for you to improve on certain aspects of quality or does it take longer?”

SOURCE: Annals of Internal Medicine, online June 1, 2021.

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