The Centers for Medicare & Medicaid (CMS) has implemented many initiatives to ensure that dialysis facilities provide high quality care to Medicare beneficiaries. These include a pay for performance program and a website where users can compare dialysis facilities to one another, among other activities geared to monitor, track and encourage improvement in the quality of care dialysis facilities provide. Now, CMS has stated it will launch a new program later this year that rates dialysis facilities using a five star rating system. NKF wanted to better understand how patients judge quality as well as determine their knowledge of Medicare’s public reporting on quality programs. Therefore, we surveyed dialysis patients and their families through an online survey and received nearly 1,000 responses. 
Medicare offers two primary ways to learn about the quality of care provided by dialysis facilities, but the majority of our survey respondents did not know of the programs nor had much understanding of them. The end-stage renal disease (ESRD) Quality Incentive Program (QIP) is a pay for performance program. Dialysis facilities can be penalized with a 2% reduction in their payments from Medicare if they do not at least meet Medicare’s established standard on quality measures. Most of the quality measures are based off lab reports and include:
- hemoglobin <12g/dl
- kT/V (dialysis adequacy)
- blood stream infections
- vascular access type
- anemia management reporting,
- bone and mineral metabolism reporting
- reporting on administration of the in-center hemodialysis patient satisfaction survey, known as the Consumer Assessment of Healthcare Providers and Services (CAHPS)
Each facility is required to post a certificate showing their scores on the QIP, and the staff in the clinic is supposed to educate patients on what the scores mean. However, after being shown an image of the certificate, 67% of our survey respondents reported they had not seen the certificate in their facility and out of those who had, 42% felt they understood the information.
Medicare also publishes quality data on a website known as Dialysis Facility Compare. Less than 4% of survey respondents reported using this website to determine the quality of care their facility provides. In addition, most patients stated they initially chose their dialysis facility based on their physician’s recommendation or how close the facility was to their home.
We also asked respondents how they defined quality at their dialysis facility and presented several options, permitting them to pick more than one item and allowing them to write in answers. The majority (81%) of patients stated that they judged quality based on the attentiveness of the facility staff.
However, most respondents also picked more than one option, and the other leading indicators of quality were the look and feel of the dialysis facility and how the patient felt daily and after a dialysis session. Judging quality based on their own lab reports was a close runner-up to how patients felt daily and after dialysis.
Now back to the Medicare programs and the expected new five star rating. The five star program will use some measures that are in the QIP, but will also include measures on the number of patients who receive blood transfusions, the percent of patients hospitalized and the death rate of patients in the facility. Stars will be awarded to the facility based on these factors, but facilities will also be graded on a curve. While there was strong support for a new Medicare rating system (71%), only 30% of patients said they were very likely to switch dialysis facilities if their facility rated poorly. So is it that CMS is out of touch with the quality measures that are most important to patients? Or, do patients feel they can’t change dialysis facilities because of other factors like how close the facility is to their home and whether their nephrologist sees patients at another clinic?
In the same way consumers can rate restaurants and other services through websites such as Yelp, perhaps CMS should let patients review their dialysis facilities if they want to help them make better decisions about where to receive their dialysis care. This way patients will see not only the criteria that Medicare thinks is important for a five star facility, but they can also see how many stars the patients give the facility and what factors they value. What do you think? Survey respondents racial and ethnic demographics were not necessarily representative of the general dialysis population as reported and tracked by the United States Renal Data System (USRDS)