What is the Quality Incentive Program (QIP)?

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

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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
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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

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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)