What to Expect from the ESRD Quality Incentive Program

By Steven Fishbane, MD

The Centers for Medicare & Medicaid Services (CMS) published the final rule for the End-Stage Renal Disease Prospective Payment System and Quality Incentive Program (QIP) on Nov. 1. This follows the proposed rule that had been published in the Federal Register on July 8, 2011.

In this article, the focus will be on the ESRD QIP. There were 88 public comments received on the QIP, and the final QIP rule reflects important changes relative to the proposed rule. The greatest changes in the QIP will be for payment year 2014. It is critically important for providers to understand the 2014 QIP because, 1) it contains major changes from previous years and 2) the performance period begins very soon: Jan. 1, 2012. This posting is a summary of the major components of the final QIP rule, with changes from the proposed rule highlighted in italics.

Minimum Number of Cases

CMS had proposed that a minimum of 11 cases at a facility was required for a measure to be included in the QIP scoring. Comments noted that this relatively small number could be problematic; for example, one patient’s results could have a disproportionately large effect on scoring. There were suggestions to increase the minimum to 20 or more cases, or to test for statistical significance. In the final rule, CMS decided to maintain the 11 case minimum, but to continue to monitor closely to assess the impact.

Payment Year 2013, Performance Period 2011

The major change for payment year 2013 (performance period 2011) is that the quality measure of percentage of patients with Hgb < 10 g/dL has been retired. This leaves two measures:

  • 15 points: Percentage of patients with Hgb > 12 g/dL (national performance 14 percent) and
  • 15 points: Percentage of patients with URR ≥ 65% (national performance 97 percent)

The only significant change from the proposed rule is small adjustments in the national performance standards.

For each percentage point that a facility underperforms the baseline (national average for 2009 or the facility’s own performance for 2007), it loses two performance points. Payment is reduced based on the total performance score; the further below the maximum of 30 points, the greater payment reduction up to a maximum of 2 percent.

PY 2013 Total Performance Score

Percentage of Payment Reduction

30 points

No reduction

26-29 points

1% reduction

21-25 points

1.5% reduction

20 points or less

2% reduction


Payment Year 2014, Performance Period 2012

The QIP for payment year 2014, performance period Jan. 1, 2012 to Dec. 31, 2012, changes substantially. The first important change is an increase from two to six total quality measures. Three of the measures are clinical, and these account for 90 percent of the Total Performance Score (TPS), the remaining three are reporting measures, accounting for 10 percent of the TPS.

The three clinical measures are:

1. Percentage of patients with Hgb > 12 g/d (0-30 performance points)

2) Percentage of patients with URR ≥ 65% (0-30 performance points)

3) Vascular access type (Average of AV fistulas in the last treatment of the month and catheters over the previous 90 days) (0-30 performance points)

Note that there are three changes from the proposed rule, instead of changing to KT/V as the dialysis adequacy measure, URR is retained; and two proposed measures, vascular access infections and the standardized hospitalization ratio did not make it into the final rule.

The three reporting measures are:

1. Reporting of dialysis safety events to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN) (up to 3/31/2013) (0-3.3 performance points)

2. Attestation of administering a patient satisfaction survey; the In-Center Hemodialysis (ICH) Consumer Assessment of Healthcare Providers and Systems (CAHPS) (0-3.3 performance points)

3. Attestation that calcium and phosphorus have been tested on at least a monthly basis (0-3.3 performance points)

It should be noted that although many entities commented on their disappointment with the retirement of the Hgb < 10 g/dL quality measure, CMS has decided that it will not reinstate this measure.

Scoring Methodology

Clinical scores make up 90 percent of the Total Performance Score, and reporting measures make up 10 percent. To determine the performance scores for clinical measures, the higher of an achievement score or an improvement score is used.

Clinical Measure Achievement Scores

The achievement score (0-10) is zero if the facility performance during 2012 is lower than the 15th percentile of national performance (the achievement threshold) during a baseline period of July 1, 2010 to June 30, 2011. Note that this is a change from the proposed rule, where the achievement threshold was one standard deviation below the mean national performance during the baseline period

The achievement score is 10 if the facility performance in 2012 is at or above the benchmark, defined as the 90th percentile of national performance in the baseline period. The benchmark is also changed from the proposed rule, when it was the mean of the top decile of national performance.

In all other cases the facility’s achievement score is between 0-10 based on the relative performance between the achievement threshold and the benchmark (15th to 90th percentile of national performance). The score may be calculated as:

  • 9 x ((facility rate in performance period – achievement threshold) / (benchmark-achievement threshold)) + 0.5

Clinical Measure Improvement Scores

The improvement score can range from 0-9 based on the facility’s improvement from its baseline period performance compared to the benchmark (90th percentile national baseline performance). It is calculated as:

  • 10 x ((facility rate in performance period – facility rate in baseline period) / (benchmark- facility rate in baseline period)) - 0.5

The higher of the achievement score or the improvement score becomes the performance score for each clinical measure.

Reporting Scores

The reporting scores make up 10 percent of the Total Performance Score (TPS). Each individual reporting score has a range of 0-10. Reporting of safety events to the CDC’s National Healthcare Safety Network earns 5 points for enrollment and training and 10 points for 3 months of reporting by 3/31/2013 (date extended compared to the proposed rule). The ICH CAHPS patient satisfaction tool reporting score leads to 10 points for attestation that it is being utilized. Similarly, the third reporting score results in 10 points on attestation that calcium and phosphorus are measured monthly.

Total Performance Score

The Total Performance Score (TPS) that determines potential payment reduction is calculated on a 0-100 scale, based 90 percent on the clinical measures and 10 percent for reporting measures. The following formula is used to derive the TPS:

  • Total Performance Score = [(.300 * Hemoglobin Greater Than 12g/dL Measure) + (.300 * URR Hemodialysis Adequacy Measure) + (.300 * Vascular Access CMS-1577-F 193 Type Measure) + (.0333 * NHSN Reporting Measure) + (.0333 * Patient Experience Survey Reporting Measure) + (.0333 * Mineral Metabolism Reporting Measure)] * 10

Payment Reduction Linked to the Total Performance Score

CMS will determine a minimum TPS, above which there would be no payment reduction. It is currently estimated that the minimum TPS will be 56 (note that this has changed slightly since the proposed rule, when the minimum was estimated to be 60). The final minimum TPS will be published by the CMS by 1/31/2012. For every 10 points that a facility’s TPS falls below the minimum TPS it will incur a 0.5 percent payment reduction up to a maximum of 2 percent (note that this is a slight change from the proposed rule, when the minimum reduction was 1 percent not 0.5 percent).


Payment Year 2014 Payment Reductions


Total Performance Score (TPS)

Percentage Payment Reduction


No Reduction







25 or below



What’s Next?

Clearly the QIP program is going to expand, primarily in the number of performance measures. Dialysis providers are well advised to become familiar with the program structure and scoring methodology. As the program expands, CMS may choose to bypass the formal rulemaking and comment process and instead introduce measures through subregulatory processes. It should be strongly encouraged that in this event, that there be highly engaged consultation with the nephrology community.

Steven Fishbane, MD, is vice president of the North Shore-LIJ Health System in Manhasset,NY and Director of Clinical Research. He is a pending professor of Medicine at the Hofstra North Shore-LIJ School of Medicine.

comments powered by Disqus