March 2014 Overview of the End-Stage Renal Disease Quality Incentive Program (QIP) Performance Year 2014 Mineral Metabolism Special Edition-March 2014 Western Pacific Renal Network, LLC What is the Quality Incentive Program (QIP)? To access important information regarding the measures adopted for each performance year as well as the payment year that is affected The ESRD Quality Incentive Program (QIP) developed by the Centers for Medicare & Medicaid Services (CMS) provides the renal community with the opportunity to enhance the overall quality of care that patients with ESRD receive. The QIP is the first Medicare program that links provider or facility payments to performance, based on outcomes assessed through specific quality measures. Click on this Website! www.dialysisreports.org Updates to the QIP measures occur each calendar year. The public is allowed to comment on proposed changes before they go into effect. Is it a federal regulation? Yes, CMS developed the ESRD QIP as mandated by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) section 153(c). MIPPA provides a mechanism for establishing standards of care and authorizes payment reductions of up to 2% for facilities failing to meet or exceed the minimum Total Performance Score (TPS) articulated by CMS for each evaluation year. If you receive Medicare reimbursement for dialysis services and meet eligibility requirements you automatically qualify to be a part of the program. For Performance Year 2014 the final rule:  Did not finalize the Patient-Informed Consent for the proposed Anemia Treatment clinical measure  Did not finalize the proposed Pediatric Iron Therapy measure Did not finalize the proposed Comorbidity Reporting measure The Hypercalcemia Clinical Measure will be given 2/3 the weight of the other clinic measures   INSIDE THIS ISSUE OSTEOPOROSIS Normal Bone 1 What is the Quality Incentive Program? 2 2014 QIP Performance Measures 3 Helpful Terms / QIP Scoring 4 What Can Facilities Do? 4 Calcium Phosphorous Resources QIP Overview 2014 Osteoporosis 2014 QIP PERFORMANCE MEASURES 2014 Reporting Measures  There are 8 Clinical Measures for Performance Year 2014 Anemia Management  Number of months the facility reports ESA dosage, hemoglobin, and hematocrit for each patient  Clinical Measures Mineral Metabolism   % of patients with mean HGB>12g/dl   % of patient-months using a catheter continuously for 90 days or longer as of the last treatment of the month Patient Experience of Care  Facility administers, using a third party CMS-approved vendor, the In-Center Hemodialysis CAHPS survey (ICH CAHPS) in accordance with specifications available at https://ichcahps.org and submits (via CMS-approved vendor) survey results to CMS Vascular Access Type  % of patient-months using AVF with 2 needles during the last treatment of the month  Number of months the facility reports serum phosphorus values for each Medicare patient  Anemia Management  Dialysis Adequacy  % of hemodialysis patient-months with spKt/V >=1.2  % of pediatric in-center patientmonths with spKt/V >=1.2  % of peritoneal dialysis patientmonths with Kt/V >= 1.7  NHSN Infection Monitoring  Number of hemodialysis outpatients with positive blood cultures per 100 hemodialysis patient-months  Hypercalcemia  Proportion of patient-months with 3-month rolling average of total uncorrected serum calcium greater than 10.2 mg/dL There are two scoring methods for the QIP. The first method is using an Achievement Score whereby points are awarded by comparing the facility’s performance rate during the performance period (CY 2014) with the performance of all facilities nationally during the comparison period (CY 2012).  10 points for rate better than or equal to benchmark QIP Overview 2014  0 points for rate worse than achievement threshold  1-9 points for rate between the two March 2014 Helpful QIP Terms Performance Year The Year in which the facility must meet or exceed the CMS quality standards finalized for that year. Clinical Measures Scores for applicable clinical measure topics will be weighted equally (except Hypercalcemia, which will be weighted at 2/3 the weight of other clinical measures) to comprise 75% of the Total Performance Score. Payment Year The Year in which Medicare payment may be reduced based on the Total Performance Score achieved by the facility in the performance year. Performance Score Report (PSR) Your performance in 2014 determines how your payment may be affected in 2016. Report that outlines the facility’s performance in the ESRD QIP for the performance year. Performance Score Certificate (PSC) Certificate provided by CMS to each facility that indicates the facility’s Total Performance Score (TPS) and scores on individual measures. Each facility is required by law to display the PSC in a prominent location. Reporting Measures Scores for applicable reporting measure topics will be weighted equally to comprise 25% of the Total Performance Score. Dialysis Facility Reports (DFR) The DFR compares patient characteristics, treatment patterns, transplantation rates, hospitalization rates, and mortality rates to local and national averages. Dialysis Facility Compare (DFC) Medicare website where patients can compare dialysis facilities using publicly reported quality measures. The other scoring method is by using an Improvement Score: Points awarded by comparing the facility’s performance rate during the performance period (CY 2014) with its own previous performance during the comparison period (CY 2013).  10 points for rate better than or equal to benchmark (per achievement score)  0 points for rate worse than improvement threshold QIP Overview 2014  1-9 points for rate between the two As you review your Performance Score Report there are some terms used that you might not be familiar with. Here are some Key Scoring Terms and additional payment information that might help you interpret your report. Performance Period: Calendar year (CY) 2014 January 1 – December 31, 2014 Performance Rate: The facility’s raw score, based on specifications for each individual measure How well the facility did, based on certain measures determined by CMS, summarized as a single number Improvement Threshold: The facility’s performance rate during CY 2013 The score for January 1 – December 31, 2013, as determined by CMS, for the facility. If your facility’s performance rate for CY 2014 is lower than its performance rate for CY 2013, the facility will be awarded 0 points for its improvement score. Achievement Threshold: The 15th percentile of performance rates nationally during CY 2012 The absolutely lowest performance rate which will allow awarding of achievement points for CY 2014 is the highest performance rate of the lowest 15% of facilities nationally during CY 2012. That is, if 15% of facilities had a performance rate below xx for CY 2012, your facility will score no achievement points for CY 2014 performance if your score is not xx or better. Benchmark: The 90th percentile of performance rates nationally during CY 2012 The minimum performance rate that will allow awarding of the maximum achievement points for CY 2014 is the lowest performance rate of the top 10% of facilities nationally during CY 2012. That is, if 10% of facilities had a performance rate of xx or better for CY 2012, your facility will score maximum achievement points for CY 2014 performance if your score is at least xx. Performance Standard (clinical measures): The 50th percentile of performance rates nationally during CY 2012 th Half of facilities, nationally, had performance scores higher, and half had scores lower, in CY 2012, than the 50 percentile. A performance score in CY 2014 that is lower than this middle score for CY 2012 will result in payment percentage reduction. That is, if your facility’s performance rate for CY 2014 is in the bottom half of performance rates for facilities nationally in CY 2012, your facility will receive reduced payment. Performance Year 2014 (Payment Year 2016) Achievement Thresholds, Benchmarks, and Performance Standards Measure Anemia Management Measure Topic Kt/V Dialysis Adequacy Measure Topic  Adult Hemodialysis  Adult Peritoneal Dialysis  Pediatric Hemodialysis Vascular Access Type Measure Topic  AVF  Catheter NHSN Bloodstream Infections* Hypercalcemia Achievement Threshold (15th Percentile) 1.2% Benchmark (90th percentile) 0.0% 86.0% 67.8% 83.0% 97.4% 94.8% 97.1% 93.4% 85.7% 93.0% 49.9% 19.9% See note 5.4% 77.0% 2.8% See note 0.0% 62.3% 10.6% See note 1.7% Performance Standard 0.0% *The achievement threshold, benchmark, and performance standard for the NHSN Bloodstream Infections measure will be set at the 15th, 90th, and 50th percentile, respectively, of eligible facilities’ performance in CY 2014. Facility Total Performance Score 100-54 53-44 43-34 33-24 23-0 Payment Reduction 0% 0.5% 1.0% 1.5% 2.0% QIP Overview 2014 Management of Calcium and Phosphorus Tips for Providers  Clinics should have a dedicated mineral metabolism manager who doses activated Vitamin D using a physician-approved algorithm or protocol Monitor facility results and trends for Ca, cCa, Phos, and iPTH and intervene if trend is negative Consider using 2.5 Ca bath as the standard and adjust as indicated by labs Consider switching from Calcium containing to non-Calcium containing binders Utilize team approach-MD for orders, RD for diet education, RNs and PCTs for reinforcement, SW for assistance overcoming barriers to adherence Encourage prompt filling/refilling of prescriptions for binders and calcimimetics      Sincere thanks to Ginny Moore, R.D., and Fay Moore, R.D., C.S.R. for their valuable contributions to this section of the newsletter! WHAT CAN FACILITIES DO TO MEET OR EXCEED THE 2014 QIP MEASURES?  Provide high-quality care and monitor outcomes  Anemia management: monitor and trend; decrease % of patients with mean Hgb >12g/dl who continue to receive ESA  Dialysis Adequacy: achieve adequacy goals for in-center, peritoneal and pediatric dialysis patients  Maximize placement of AVF and minimize Catheter use  Monthly NHSN Reporting; use CDC tools to reduce bloodstream infections  Monthly reporting of Calcium and Phosphorus  Monthly reporting of ESA dose and hemoglobin/hematocrit  Administer the ICH CAHPS using a third-party vendor  Preview the Performance Score Report and submit comments within specified timeframe if you have questions regarding data Patient Education Key Points: High Phosphorus Foods to Avoid  Assess readiness for and barriers to change  Teach diet principles including label reading  Avoid foods high in Phosphorus and Phosphorus-containing ingredients and additives  Avoid Calcium-fortified food products, beverages and medications   Reinforce binder rationale, timing, dose and timely refills   Encourage adherence to medications and diet  Conduct adherence programs like lobby days, contests with prizes, puzzles or recipes  Provide patient education on relationship of lab values to calcification and calciphylaxis  Utilize a team approach where all disciplines are involved in providing education  Strive for consistent messages within the clinic to avoid confusion         QIP Overview 2014 Phosphorus-containing additives-like phosphoric acid and phosphates Dairy products limited to 4 ounces per day Cola and pepper-type soft drinks Convenience foods, fast foods Processed chicken and pre-cooked chicken products Enhanced or injected meat products Organ meats Cheese limited to 3 ounces per week Chocolate Beer CLINICAL MEASURES RESOURCES REPORTING MEASURES RESOURCES ANEMIA MANAGEMENT: Anemia Management: http://www.dialysisreports.org/pdf/esrd/publicmeasures/AnemiaManagement-HGB-2016FR.pdf http://www.dialysisreports.org/pdf/esrd/publicmeasures/AnemiaManagement-Reporting-2016FR.pdff KT/V DIALYSIS ADEQUACY MEASURE TOPIC:  Adult Hemodialysis: http://www.dialysisreports.org/pdf/esrd/publicmeasures/HemodialysisAdequacy-ktv-2016FR.pdf  Adult Peritoneal Dialysis: http://www.dialysisreports.org/pdf/esrd/publicmeasures/PeritonealDialysisAdequacy-ktv-2016FR.pdf  Pediatric Hemodialysis: http://www.dialysisreports.org/pdf/esrd/publicmeasures/PediatricHemodialysisAdequacy-ktv-2016FR.pdf  Vascular Access type measure topic  AVF:http://www.dialysisreports.org/pdf/esrd/publicmeasures/VascularAccess-Fistula-2016FR.pdf  Catheter:http://www.dialysisreports.org/pdf/esrd/publicmeasures/VascularAccess-Catheter-2016FR.pdf  Hypercalcemia: http://www.dialysisreports.org/pdf/esrd/publicmeasures/MineralMetabolism-Hypercalcemia2016FR.pdf  NHSN Bloodstream Infection Monitoring: http://www.dialysisreports.org/pdf/esrd/publicmeasures/NHSNBloodstreamInfection-2016FR.pdf ICH CAHPS: http://www.dialysisreports.org/pdf/esrd/publicmeasures/ICHCAHPS-2016FR.pdf Mineral Metabolism: http://www.dialysisreports.org/pdf/esrd/publicmeasures/MineralMetabolism-Reporting-2016FR.pdf NHSN Dialysis Event Reporting: http://www.dialysisreports.org/pdf/esrd/publicmeasures/NHSNBloodstreamInfection-2016FR.pdf Other Helpful Sites:  ESRD Network Coordinating Center (NCC) www.esrdncc.org  Dialysis Facility Reports: www.DialysisReports.org  2009 KDIGO Guidelines for Treatment of Mineral Bone Disorders http://www.kdigo.org/pdf/KDIGO%20CKDMBD%20GL%20KI%20Suppl%20113.pdf QIP Questions? ESRDQIP@cms.hhs.gov QIP Website You may obtain additional information regarding the Centers for Medicare & Medicaid Services Quality Incentive Program for dialysis care @ http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/ESRDQIP/index.html. The site offers many resources for dialysis providers, including updates, proposed and final rules, and access to slide forums from CMS-directed open door meetings. Disclaimer The QIP informational brochure is a collaborative effort written, designed, and distributed by Western Pacific Renal Network #17 and Intermountain End-Stage Renal Disease Network #15. This brochure is published while under contract with the Centers for Medicare and Medicaid Services Contract #HHSM-500-2013-NW017C and Contract #HHSM-500-2013-NW015C. The information regarding the CMS Quality Incentive Program applies only to Performance Year 2014. The opinions and conclusions expressed are those of the authors. They do not necessarily reflect CMS policy. Intermountain ESRD Network, Inc. 165 S Union Blvd., # 466 Lakewood, CO 80228 303-831-8818 (phone) 303-831-1612 (QI fax) Western Pacific Renal Network, LLC 505 San Marin Dr., A-300 Novato, CA 94945 415-897-2400 (phone) 415-897-2422 (QI fax)