July 14, 2003 - For six months, physicians have been working to satisfy requirements outlined in the nation's most ambitious attempt to offer bonuses for quality care. But they've done so without really knowing what they'll be paid for their efforts. Article from American Medical News.
On July 10, HHS Secretary Tommy G. Thompson announced a new Medicare demonstration program that will use financial incentives to encourage hospitals to provide high quality inpatient care. The demonstration involves Premier Inc., a nationwide organization of not-for-profit hospitals, and will reward participating hospitals that provide high quality care by increasing their payment for Medicare patients. Participating hospitals will report quality data that CMS will use to determine high-performing hospitals. Press release from the HHS.
July 2, 2003 - Dialysis units could see a new kind of facility inspector - federal prosecutors.
Federal prosecutors increasingly are looking to prosecute providers who defraud government programs via inadequate patient care.
James Sheehan, the assistant U.S. attorney in Philadelphia whose office began the series of False Claims Act lawsuits against local nursing homes in the 1990s, says the category of providers has expanded beyond nursing homes to residential psychiatric treatment centers, dialysis centers and other institutions where patient healthcare options are limited.
A special report on this development is in the current issue of Modern Healthcare. Registration is required to read the articles, but viewing is free:
June 17, 2003 - In its latest report to Congress, the Medicare Payment Advisory Commission (MedPAC) said that CMS should test ways to link reimbursements to quality of care. Reinforcing a message delivered repeatedly by CMS Administrator Tom Scully, MedPAC said providers that deliver the best care for the lowest cost should be rewarded with higher payments. Press release from MedPAC (pdf).
Chapter 6 (pdf) of this report, Quality of dialysis care and providers� cost, addresses paying for outpatient dialysis services. The chapter concludes with these Implications and Next Steps:
"Our analysis shows that the quality of dialysis care is not linked to the cost per treatment for composite rate services. This finding suggests that providers are not stinting on furnishing composite rate services. The lack of a relationship between dialysis quality and composite rate costs also suggests that many dialysis providers have responded to the economic incentives created by Medicare�s prospective payment system and reporting system by improving productivity without compromising quality. The opposite interpretation � that all facilities are stinting on composite rate services � is less likely given the substantial and clinically significant improvement in hemodialysis adequacy and anemia status since 1993.
Considering both costs for furnishing dialysis and injectable drugs together, we find that beneficiaries� outcomes are poorer for facilities with higher than average costs. One interpretation is that, since these drugs are paid on a per dose basis, some providers may not furnish these drugs as efficiently as if they were paid for prospectively. The profitability of injectable drugs subsidizes the lower margins under the composite rate and may provide incentives for their overuse, to the extent possible, by certain providers. Spending varies widely for injectable dialysis drugs by Medicare; for instance, in 2000, per patient per month spending for intravenous iron and vitamin D analogues varied by a factor of two between freestanding dialysis facilities based on their chain affiliation and profit status (USRDS 2002).
Alternatively, this finding may suggest that higher-cost facilities may be furnishing care to more medically complex beneficiaries. As noted earlier, providers have the incentive to furnish as many of these drugs as the severity of the patient warrants since these injectable drugs are paid on a per dose basis. Our model, however, adjusts outcomes for medical complexity by including information about beneficiaries� demographic characteristics, duration of dialysis, 16 comorbidities, and functional status. However, there may be some unresolved case-mix differences. Either interpretation supports previous MedPAC recommendations:
As discussed in Chapter 7, the Commission believes it is important for Medicare to explore the use of nonfinancial and financial incentives to improve quality of care. To date, Medicare has only used nonfinancial incentives, particularly public disclosure of quality of care information, to improve quality in both the traditional Medicare program and Medicare+Choice. Currently, the payments providers receive for the higher-quality are they produce are no higher than they ould be for lower-quality care. Having a set of credible, broadly understood, and accepted measures of quality is a critical component of designing incentives. Based on these criteria, implementing both on financial and financial incentives for dialysis providers is more feasible than for others. As mentioned earlier, CMS measures and publishes information on dialysis quality nationally and for individual facilities.
CMS accomplished the positive trend in improving dialysis adequacy and anemia status since the mid-1990s without the use of financial incentives by Medicare. Rather, quality improvement efforts undertaken by providers and the end-stage renal disease (ESRD) networks and CMS�s efforts in measuring and reporting dialysis quality have influenced dialysis quality. Both nonfinancial and financial incentives, however, might be useful tools to improve other processes of dialysis care.
One area increasingly recognized as a critical component of care is the management of hemodialysis patients� vascular access. Vascular access care accounts for about 10 percent of Medicare spending for hemodialysis patients and is the second leading reason for hospitalization for these patients (USRDS 2002). In 1999, CMS began reporting on three measures of vascular access management in its Clinical Performance Measurement Project.12 This quality measure, however, is not publically reported for individual facilities by the agency. CMS data show that opportunities exist to enhance beneficiaries� quality of care by modifying vascular access practice patterns. For instance, only 30 percent of hemodialysis patients had arteriovenous fistulas, the vascular access type recommended in the clinical guidelines developed by the NKF, compared with 46 percent of patients with arteriovenous grafts and 24 percent with catheters (CMS 2002). In addition, only 47 percent of patients with an arteriovenous graft had the graft routinely monitored for the presence of stenosis.
Dialysis facilities, nephrologists, vascular surgeons, and radiologists together make decisions about beneficiaries� vascular access care. Publically reporting vascular access measures for individual facilities on CMS�s Dialysis Facility Compare website may be one way to improve the quality of vascular access care. Financial incentives also should be considered if public disclosure alone does not result in improvement.
Finally, there are other measures of dialysis quality in addition to the four measures used in this analysis. The NKF has developed clinical guidelines for vascular access management, adequacy of peritoneal dialysis, and nutrition management. CMS nationally reports these measures in its Clinical Performance Measurement Project. This study did not include the measures of vascular access management and peritoneal dialysis adequacy because of data reliability and availability issues. We did not include the measures of nutrition management because Medicare�s payment policies restrict the number of beneficiaries who qualify for nutritional interventions. We also did not assess the relationship between other outcomes of care�patient satisfaction and reasons for hospitalization�and providers� costs because of data availability issues. In the future, it may be fruitful to assess the relationship between these processes and outcomes of dialysis care and providers� costs."
Chapter 9 contains references to drugs in the dialysis outpatient setting.
"Report to the Congress: Variation and Innovation in Medicare" (June 2003) full report (pdf).
[This message has been edited by Gary Peterson (edited 08-18-2003).]
