Does the ESRD QIP Really Drive Quality Improvement—or Risk Patients?

This blog post was made by Beth Witten, MSW, ACSW, LSCSW on October 12, 2023.
Does the ESRD QIP Really Drive Quality Improvement—or Risk Patients?

In 2012, CMS launched the ESRD Quality Improvement Program (QIP), under which data are collected during a specific calendar year and reductions—if any—take place 2 years later. So, for example, data collected in calendar year (CY) 2010 affected Medicare reimbursement for dialysis in payment year (PY) 2012. To learn if a clinic has a payment reduction, each measure is weighted and summed to yield a “total performance score” (TPS). If the TPS is too low, CMS reduces payment for each of the clinic’s patients for the whole year by 0.5%, 1.0%, 1.5%, or 2%, depending on how low the TPS is.1

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According to a fact sheet CMS published in November 2011, “The QIP is designed to improve patient outcomes by establishing payment incentives for dialysis facilities to meet performance standards established by CMS. Under the ESRD QIP, for the first time, payments are tied to the quality of care beneficiaries receive at the facilities.”2 Questions this blog will attempt to answer are: What does the ESRD QIP measure, and how? How many facilities have payment reductions? How do payment cuts affect clinics: And, are there unintended consequences of the ESRD QIP?

What Does the ESRD QIP Measure, and How?

The four tables below describe the ESRD QIP for a specific payment year. Each table includes:

  • List of measures

  • Performance period when data are reported

  • Comparison period if applicable (PY 2014 on)

  • Performance standard

  • Measure weighting

  • Minimum data requirements (minimum cases per measure to be counted)

  • Low-volume facility adjustment if applicable

  • Maximum total performance score (PY 2012-2016 only)

  • Minimum total performance score

  • Payment reduction scale (PY 2012-2016 only)

  • Information about reporting measures (PY 2012-2016 only)

What follows is a table showing how the QIP measures and the TPS changed over time. The sources are for a table that goes into greater detail.

QIP PY / CY QIP Measures
2012 / 2010

3 Clinical: Hgb >12 g/dL, Hgb <10 g/dL, URR > 65%)

Min TPS 26 points; minus 0.5/5 points less

2013 / 2011

2 Clinical: -1 Hgb <12 g/dL, URR >65%)

Min TPS 30 points; minus 0.5/5 points less

2014 / 2012

3 Clinical: Hgb, URR, vascular access type (VAT)

3 Reporting: add the CDC National Healthcare Safety Network (NHSN), ICH CAHPS Mineral Metabolism

Min TPS 53 points; minus 0.5/10 points less

2015 / 2013

6 Clinical: delete VAT (graft); add Kt/V (HD, PD, peds)

4 Reporting: same plus Anemia Management

Min TPS 60 points; minus 0.5/10 points less

2016 / 2014

CY 2012 achievement

CY 2013 improvement

8 Clinical: same plus NHSN bloodstream infection (BSI) HD, Hypercalcemia

3 Reporting: same minus NHSN

Min TPS 54 points; minus 0.5/10 points less

2017 / 2015

CY 2013 achievement

CY 2014 improvement

(2014 both for NHSN)

8 Clinical: delete Hgb, add Std Readmit Rate

Same Reporting

Min TPS 60 points

2018 / 2016

CY 2014 achievement

CY 2015 improvement

(2015 both for CAHPS)

11 Clinical: same plus CAHPS, Kt/V peds PD, Std Transfusion Rate

5 Reporting: same plus pain assess/f/u, clin depression screening/f/u, NHSN staff flu vaccine

Min TPS 49 points

2019 / 2017

CY 2015 achievement

CY 2016 improvement

7 Clinical: minus NHSN, add Kt/V comprehensive vs. each type

2 Safety: NHSN BSI clinical & dialysis event reporting

5 Reporting: same

Min TPS 60 points

2020 / 2018

CY 2016 achievement

CY 2017 improvement

8 Clinical: add SHR

2 Safety: same

6 Reporting: add UFR

Min TPS not established by April

2021 / 2019

CY 2017 achievement

CY 2018 improvement

1 Patient/Family Engagement: CAHPS

3 Care Coordination: SRR, SHR, Clinical Depression Screening/FU

6 Clinical Care: Kt/V comp, VA (SFR, LT Cath Rate), STrR, Hypercalcemia, URR

2 Safety: NHSN BSI Clinical, NHSN Dialysis Event Reporting

Min TPS 56 points

2022 / 2020

CY 2018 achievement

CY 2019 improvement

1 Patient/Family Engagement: same

4 Care Coordination: added Percent Prevalent Patients Waitlisted

Same Clinical Care

3 Safety: add Medication Reconciliation (MedRec)

No TPS calculated (COVID-19 PHE)

2023 / 2021

CY 2019 achievement

CY 2020 improvement

Same measures as prior year

Min TPS 83 points

2024 / 2022

CY 2020 achievement

CY 2021 improvement

Same measures as prior year

Min TPS 57 points

2025 / 2023

CY 2021 achievement

CY 2022 improvement

Clinical Depression & FU moved from Care Coordination to Reporting; NHSN Dialysis Event Reporting moved from Safety to Reporting; Hypercalcemia & UFR moved from Clinical Care to Reporting

Min TPS 55 points


How Many Clinics Have Payment Reductions?

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Dialysis clinics strive to avoid Medicare payment cuts. Clinic managers want to meet or exceed measure targets during the calendar year when data are reported. To find out how many clinics have reimbursement cuts, I downloaded the QIP data for PY 2021, 2022, and 2023. I learned that although CMS data files for PY 2022 and 2023 include data for QIP measures, due to the COVID-19 public health emergency (PHE), CMS chose not to reduce any clinic’s payment for those years and the database had “NA” in the payment reduction column. The PY 2021 data collected during 2019 were reported the year before COVID-19 PHE. That file included performance scores and payment reduction percentages. In CY 2021, clinics whose TPS was 57 or higher had no reduction. Below are dialysis companies with 100 clinics or more and the numbers of reimbursement cuts.

CY 2021 QIP Reimbursement Status by Clinic Ownership*
Dialysis Company

No Cuts

TPS 57-100

0.5% Cut

TPS 47-56

1.0% Cut

TPS 37-46

1.5% Cut

TPS 36-27

2% Cut

TPS 0-26

Total # Clinics
All 4679 (61%) 1609 (21%) 929 (12%) 297 (4%) 111 (1%) 7,625
ARA 154 (63%) 54 (22%) 27 (11%) 6 (2%) 2 (<1%) 243
DaVita 1909 (67%) 607 (21%) 273 (10%) 52 (2%) 7 (<1) 2,848
DCI 178 (70%) 39 (15%) 27 (11%) 7 (3%) 3 (1%) 254
Fresenius 1604 (61%) 598 (23%) 333 (13%) 98 (4%) 13 (<1%) 2,646
Independent 402 (48%) 143 (17%) 149 (18%) 73 (9%) 65 (8%) 832
USRC 146 (53%) 55 (20%) 47 (17%) 22 (8%) 4 (1%) 274

Green shading indicates percentage(s) better than the national average indicated in green text.

*NOTE: These data do not reflect companies acquired but not listed as owned by entities in the table. These include a few clinics designed as DSI, Gambro, Liberty Dialysis, Renal Care Group, and Renal Ventures. The table also does not include companies with fewer than 100 clinics.

How do payment cuts affect clinics?

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In CY 2021, 61% of dialysis clinics had no Medicare payment reduction and 33% had cuts of 1% or less. Just 5% had cuts of 1.5% or more. A higher percentage of US Renal Care (52%) and clinics CMS described as “independent” (47%) had reimbursement cuts.

In CY 2021, the Medicare allowed charge under the base ESRD prospective payment system (PPS) that year was $253.13. Medicare routinely pays 80% of that amount per patient per treatment for 3 HD treatments/week or 156 HD treatments per patient per year. PD payment for 7 days is the same as a week of HD. So, assuming the QIP cut is from what Medicare would pay a clinic that received no QIP cut or $202.50 (80% of the ESRD PPS) then:

  • A loss of .5% or $1.01 per patient/treatment x 156 = $157.56 less per patient/year.

  • A loss of 1% or $2.03 per patient/treatment x 156 = $316.68 per patient per year.

  • A loss of 1.5% or $3.04 per patient per treatment x 156 = $474.24 per patient per year.

  • A loss of 2% or $4.05 per patient per treatment x 156 = $631.80 per patient per year.

The larger the dialysis organization, the lower the impact if one or a few clinics have cuts. And large dialysis organizations (LDOs) can share clinical expertise and data across clinics under their management. They may be able to identify areas needing improvement more easily. This gives them an advantage in being able to develop and implement interventions to improve future QIP scores.

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Are There Unintended Consequences of the ESRD QIP?

Dialysis Facility Compare uses some QIP data to determine how many stars (1-5) a clinic has. A study of these data from October 2015 to April 2018 found that the percentage of clinics with 4 or 5 stars increased from 30% to 53.4%. Independent clinics had lower odds than LDOs of showing year-to-year-improvement.3

Studies of QIP goals and outcomes have had some interesting findings:

  • A study that looked at the QIP goals for vascular access rates found the goals of reducing catheters to below 10% and increasing fistulas to 68% were not achieved. The authors reported lower fistula rates in clinics treating patients in Black Zip Code Tabulation Areas where incomes were under $45,000.4

  • A study looking at social risk factors found that clinics that treated a higher proportion of Black and dual eligible patients were more likely to have reimbursement cuts and patients with worse outcomes.5

  • Another study found that facilities with more patients who had higher comorbidities, were Black, or had Medicare and Medicaid had lower QIP scores. Mortality rates were higher in clinics with low scores and rose as reimbursement cuts increased. Clinics with better QIP scores the following year had lower death rates.6

If a single independent clinic or a clinic in a small chain has a low score that results in a reimbursement cut, might that cause greater financial stress on a single clinic or small chain than on a large one? Independent clinics and small chains may not have the same personnel expertise, data resources or financial reserves as an LDO. Revenue loss combined with lack of other resources to improve a clinic’s QIP score might target a clinic for closure or acquisition or encourage a clinic to refuse to treat patients requiring more time and effort because of their more challenging needs.

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Increased anxiety among clinic managers, dialysis staff, and patients can affect interactions. High caseloads and conflicts between patients or among patients and staff may reduce staff job satisfaction leading trusted staff to leave. If patients do not have confidence in new staff and feel unsafe, that could affect how they talk with staff and what they do which could risk their access to ongoing outpatient dialysis care. This is when it’s especially important for dialysis staff to have cultural competence and excellent listening and communication skills.

I don’t think we know how much social determinants of health contribute to a clinic’s QIP score and negative patient outcomes. In the 2024 proposed rule for the ESRD prospective payment system and QIP, CMS proposes to add a Screening for Social Drivers of Health measure and a Screen Positive Rate for Social Drivers of Health reporting measure. If these remain in the final rule, researchers will be able to look more closely at whether the QIP as currently designed contributes to health inequities and penalizes smaller clinics as well as those that treat patients with more complex medical and psychosocial needs.

  1. CMS. ESRD QIP Payment Year 2012 Program Details. February 1, 2013.↩︎

  2. CMS. Fact Sheet. Medicare sets framework for the ESRD Quality Incentive Program for PYs 2013 and 2014. November 1, 2011.↩︎

  3. Salerno S, Dahlerus C, Messana J, Wisniewski K, Tong L, Hirth RA, Affholter J, Gremel G, Wu Y, Zhu J, Roach J, Balovlenkov Rn E, Andress J, Li Y. Evaluating national trends in outcomes after implementation of a star rating system: Results from dialysis facility compare. Health Serv Res. 2021 Feb;56(1):123-131.↩︎

  4. Shah S, Feustel PJ, Manning CE, Salman L. CMS ESRD quality incentive program has not improved patient dialysis vascular access. J Vasc Access. 2023 Mar;24(2):246-252.↩︎

  5. Breck A, Marr J, Turenne M, Esposito D. The Role of Social Risk Factors in Dialysis Quality and Patient Outcomes Under a Medicare Quality Incentive Program. Med Care. 2022 Oct 1;60(10):735-742.↩︎

  6. Griffin SM, Marr J, Kapke A, Jin Y, Pearson J, Esposito D, Young EW. Mortality Risk of Patients Treated in Dialysis Facilities with Payment Reductions under ESRD Quality Incentive Program. Clin J Am Soc Nephrol. 2023 Mar 1;18(3):356-362.↩︎



    Oct 12, 2023 9:55 PM

    The QIP system was never intended to improve care, it is just another way for CMS to claim they are trying to improve care and outcomes "for the benefit of the patient" but in reality the small, rural units can't afford even the .5% payment cut. The QIP has one goal, to reduce the ESRD payment in any way they can.
    The CMS PPS payment is based on COST, so if CMS is reducing your payment then they are reducing your ability to provide care at the COST level. They include measures the facilities cannot control due to the measure being dependent on the patient participating in improving their clinical outcomes and honestly most of our patients are not invested getting fistulas, reducing their calcium and phosphorous, taking care of infections, etc.
    As a small, independent provider in 7 rural areas in the midwest, the QIP system is enormously hurtful both to the financial viability of the rural unit but also to the Morale of our staff. When your staff are killing themselves to take care of their patients in a very tight reimbursement environment and then you have to publish a 55 TPS score in your waiting room - it is so hurtful to our staff and so unfair. CMS wonders why the healthcare workers are leaving our field?? They are clueless about the impact these goals are, especially in units with low census. Year after year CMS refuses to recognize the QIP system is not a Carrot - it is a baseball bat aimed at those dedicated staff who make so many sacrifices to care for our patients. It is disgusting what they are doing to our industry.
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    • Beth Witten

      Oct 22, 2023 8:35 PM

      I agree that it has to be frustrating to work very hard with too few staff and too many patients and then to have the government set so many measures for dialysis clinics to meet when the measures CMS is tracking seem not be the most important things patients care about. So, IMO the key is to help patients see "what's in it for me" through patient-centered education that is at their level of health literacy and recognize that we're asking them to make difficult changes to reach targets that are important to clinics from a revenue standpoint. When dialysis staff have too many patients to care for, there may not be sufficient time to provide the education and the empathy that patients need most. IMO we should not blame patients when it is the system that is failing staff and patients.
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