Kidney Patients Join Industry In Opposing CMS’ Dialysis Star Rating System

August 8, 2014

Published by Inside Health Policy
John Wilkerson
August 8, 2014

Kidney patients have joined the fight against the Medicare star-rating program for dialysis facilities, and they’re making the same arguments as industry. Patient advocates say that the bell curve nature of the program will confuse patients, especially those in poor areas; the program is inconsistent with the existing dialysis Quality Incentive Program; and CMS should have sought feedback from patients and providers before forcing the program on them.

The chain dialysis company DaVita recently went public with complaints about Medicare’s Five-Star Quality RatingSystem for end-stage renal disease. This week, the patient-advocate group Dialysis Patient Citizens and Kidney Care Partners, which represents patients and providers and drug makers, sent letters to CMS making the same arguments.

The groups say the bell curve methodology will confuse patients. They say star ratings typically are used for discretionary purchases, such as movies and restaurants, and they’re not graded on a curve that rate a fixed percentage of facilities as one- and two-star, even if they perform well. In the case of dialysis facilities, some are located in poor areas where results tend to be worse and outside the control of providers, they note.

Dialysis Patient Citizens emphasizes the socio-economics argument in its letter to CMS. Congressional Medicare advisers and the National Quality Forum both recommend moving toward adjusting performance scores for elements beyond the control of providers, such as poverty. The group gives examples of impoverished regions such as Opelousas, LA, where patient outcomes are poor at dialysis facilities compared to facilities in healthier parts of the country like Boulder, CO, even though there are multiple companies with different staff and policies in each region.

“It strikes us as a highly unlikely coincidence that eleven different providers with eleven different staffs but serving similar populations would all show poor outcomes solely because their clinical skills are similarly substandard,” the group writes. “What seems more likely is that quality measures are conveying information about the poor population health in the region: St. Landry Parish has a premature death rate (years of potential life lost before age 75 per 100,000
population) that is double the national average, and nearly triple the rate of Boulder County, Colorado, against whose dialysis clinics those in Opelousas must compete for stars.”

The bell curve approach hurts patients in two ways, the Dialysis Patient Citizens state. First, Medicare cuts reimbursement to facilities in poor areas, which hurts their ability to deliver services. Second, the poor scores discourage and confuses patients in those areas, which is all the worse given that dialysis isn’t a discretionary service.

“It is not clear to us precisely what our hypothetical Opelousas patient is supposed to do upon being informed that all of his or her nearby options are one- or two-star facilities,” the group writes.

The Dialysis Patient Citizens recommend that CMS only give one- and two-star ratings to facilities that CMS knows have substandard clinical practices and management based on inspections. The group also believes that CMS should follow the advice of the Medicare Payment Advisory Commission and compare facilities serving patient populations.

The Kidney Care Partners, of which Dialysis Patient Citizens is a member, said CMS should scrap the October start date and work with providers and patients on a better approach.

“However, if CMS believes an October launch is necessary, it should rely upon the percentage measures and QIP benchmarks to establish the first iteration of star ratings,” the coalition states. “From there, we could work together to determine how future iterations should be designed.”

Patient advocates and industry also complain that the star-rating program is inconsistent with the Quality Incentive Program, which Medicare has used to rate dialysis facilities for more than a decade. Facilities must post QIP scores, and inevitably there will be facilities, such as those in poor regions, with good QIP score and one- and two-star ratings. In the QIP, 43 percent of facilities are in the top performance tier and receive no penalty, but the star-rating program allows only 10 percent of facilities to qualify for five stars.

“[I]f CMS gives a facility one star, consumers will not understand that the rating is on a bell-curve,” the Kidney Care Partners letter states. “They will assume that it is a low-quality facility.”–John Wilkerson (

See the original article here.