July 26, 2006
MINUTES
KIDNEY CARE QUALITY ALLIANCE MEETING
July 26, 2006
Summary
On Wednesday, July 26, 2006 the Kidney Care Quality Alliance (the Alliance) convened its first meeting at the University Club in Washington, D.C.
The purpose of the meeting was to present the Kidney Care Quality Initiative (KCQI) clinical measures, pediatric domain, and quality of life recommendations to the Alliance. Representatives of the following organizations participated at the meeting:
American Health Care Association (AHCA)
Amgen American Nephrology Nurses Association (ANNA)
Centers for Medicare and Medicaid Services (CMS)
DaVita Inc.
Federation of American Hospitals
Fresenius Medical Care North America
Johns Hopkins Medicine, Division of Pediatric Nephrology
Kidney Care Partners (KCP)
National Kidney Foundation (NKF)
National Medical Association (NMA)
National Partnership for Woman and Families
Patton Boggs LLP
Renal Physicians Association (RPA)
Society of General Internal Medicine (SGIM)
Welcome and Description of the Kidney Care Quality Initiative and Kidney Care Quality Alliance – Kent Thiry, Chairman of Kidney Care Partners; Chairman and CEO of DaVita Healthcare Partners, Inc.
Kidney Care Partners (KCP) Board of Directors Chairman Kent Thiry thanked everyone for attending the first meeting of the Kidney Care Quality Alliance.
He expressed excitement for having reached this phase of the Kidney Care Quality Initiative (KCQI).
Mr. Thiry stated the KCQI objectives, which are to define, assess, monitor, and reward quality in the treatment of Chronic Kidney Disease (CKD) and End-Stage Renal Disease (ESRD). He described the KCQI process, which emphasizes transparency, collaboration, and fairness. He informed the Alliance members that the process is open and transparent.
Mr. Thiry identified all KCQI players. Analogizing KCP as the “United Nations” of the kidney care community, he described the KCP Board as the General Assembly that has considered all measures, provided feedback, and approved the quality recommendations by consensus.
The Steering Committee has functioned like the Security Council, guiding the recommendations between the four Work Groups that developed them, the KCP Board, and the broader alliance.
Mr. Thiry described the purpose of the Alliance and of the meeting.
He explained that between KCP’s 28 member organizations, it has the expertise to develop measures to improve the quality of kidney care.
He explained that Alliance members must determine if the recommendations will be beneficial to the stakeholders they represent and to American health care in general.
Mr. Thiry identified three specific objectives of the meeting, to present the work product to the Alliance, start a dialog about the recommendations, and develop a process for formally reviewing and voting on the quality measures.
Remarks from CMS – Barry Straube, Chief Medical Officer and Director of the Office of Clinical Standards and Quality
arry Straube, MD, Chief Medical Officer and Director of the Office of Clinical Standards and Quality at CMS thanked Mr. Thiry and KCP for taking the initiative to get out in front of pay-for-performance and quality reform.
He compared the activities of other quality alliances, including the Hospital Quality Alliance (HQA), the Ambulatory Care Quality Alliance (AQA), the Pharmacy Quality Alliance (PQA), the Cancer Care Quality Alliance (CCQA), with the Kidney Care Quality Alliance (KCQA).
Dr. Straube identified several principles common to successful quality alliances that CMS supports but does not mandate.
These are a broad stakeholder representation, a consensus process, pre-endorsement, transparency, approval from the National Quality Forum, and the incorporation of data collection and pay-for-performance in the model.
Dr. Straube provided an overview of the short history of quality alliances. Section 501(b) of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) called for the creation of a hospital quality alliance and established financial incentives for data reporting.
He noted that the Deficit Reduction Act of 2005 (DRA) increased the financial incentives for data reporting and laid the foundation for outcomes-based pay-for-performance models.
He compared the Alliance to the AQA, which has a similar mission statement, develops measures in work groups, and is based on consensus. Dr. Straube recommended that like AQA, the Alliance define a set of goals for itself.
Dr. Straube expressed his optimism for the Alliance and commended them for being ahead of the curve on quality, with a very solid work product. He had several recommendations for the Alliance.
He advised it commission work groups to address data collection, rural care, home dialysis, high-risk populations, and pharmacy issues. He also proposed a public relations strategy for communication with Congress and the agencies, press, and the public.
Dr. Straube reiterated his praise for the KCQI and urged the Alliance to commit to a transparent, open process. He explained that increasing transparency in health care is a top priority for the Bush administration.
The Current Context of the ESRD Community – Ed Jones, Renal Physicians Association
Dr. Edward Jones from the Renal Physicians Association spoke about existing quality initiatives in the kidney care community and how they differentiate kidney care from other segments of the health care community.
These initiatives include the National Kidney Foundation’s (NKF) Kidney Disease Outcomes Quality Initiative (KDOQI), United States Renal Data System (USRDS), and CMS’ ESRD Clinical Performance Measures (CPM) Project, ESRD Networks Quality Mission, Medicaid Demonstration Projects, and Fistula First initiative.
Dr. Jones explained that these programs provide the framework for the development of measures that could be used in a pay-for-performance program.
He described how Phase I of the KCQI focuses on a starter set of measures for which there is a clear consensus. He noted some of the opportunities and challenges to improving quality in kidney care, indicating the physician reporting infrastructure will need to be improved before they can be evaluated on performance.
In closing, Dr. Jones emphasized the steps the kidney care community has already taken to improve the quality of care and their success thus far.
Overview of the KCQI Phase I Guiding Principles – Gail Wick, American Nephrology Nurses’ Association
Gail Wick, M.H.S.A., B.S.N., R.N., C.N.N., of the American Nephrology Nurses’ Association described the KCQI Phase I Guiding Principles.
Ms. Wick stressed that the KCQI is not starting from scratch, but has a plethora of clinical information with which to use.
In developing the Guiding Principles, the group looked at the work of the Institutes of Medicine, the Ambulatory Care Quality Alliance, the American Hospital Association, the American Medical Association, and the Joint Commission on Accreditation of Healthcare Organizations.
The Guiding Principles are divided into different sections. The General Principles provide guidance for all of the Work Groups and the process as a whole. They include:
1- a transparent process,
2- an executable work product, and
3- recommendations that will not encourage “cherrypicking.” The Steering Committee also adopted Guiding Principles specific to each of the Work Group.
She highlighted the Principles for Clinical Measures, Quality of Life, and Pediatrics.
For a more detailed description of the guiding principles, please see the KCQI Phase I Guiding Principles document.
Review of KCP RecommendationsPresentation and Discussion of Clinical Measures – Charles McAllister, Chief Medical Officer, DaVita Healthcare Partners, Inc.
Charlie McAllister, MD, Chief Medical Officer of DaVita Inc., summarized the Clinical Measures Work Group’s approach and the Clinical Measures Recommendations that have cleared the Work Group, the Steering Committee, and the KCP Board.
He stressed that the measures are not guidelines or standards, but specific tools designed to measure performance.
Dr. McAllister described the Work Group’s process, which began on December 7, 2005, and centered on adopting a set of process- and outcomes-based measures supported by the literature. He detailed the Work Group’s consideration of many areas of care before approving four facility measures and four physician measures.
He recounted their work with a methodologist to establish the numerators, denominators, and exclusion methodology for each measure. He addressed three recommendations from members of the KCP board including, an interest in unifying physician and facility measures, a concern about the proportion of exclusions, and the importance of bone and mineral metabolism treatment.
He also addressed questions from Alliance members about the exclusions.
For a more detailed description of the work product, please see the Clinical Measures Work Group Phase I Recommendations document.
Presentation and Discussion of Pediatric Domain Recommendations – Barbara Fivush, Professor of Pediatrics Division, Chief of Pediatric Nephrology Johns Hopkins Hospital
Barbara Fivush, MD, Professor and Pediatric Nephrology Division Chief at Johns Hopkins Hospital, outlined the Pediatric Work Group’s recommendations that passed the KCP Board in March.
She thanked the Alliance for including pediatric nephrology in the KCQI, but insisted that the field is not yet ready for pay-for-performance measures. She identified the problem as a lack of clinical measures and explained that KDOQI and other initiatives have established guidelines for pediatric nephrology, but have not developed evidence-based measures. She also warned against applying adult nephrology measures to the unique pediatric population.
She explained the Work Group’s conclusion that the pediatric division begin reporting with all of nephrology, but not be measured until there are fully developed clinical standards (within one to three years).
For a more detailed description of the work product, please see the Pediatric Work Group Phase I Recommendations document.
Presentation and Discussion of Quality of Life Recommendations – Charles McAllister, Chief Medical Officer of DaVita Healthcare Partners, Inc.
Standing in for Dr. William McCellan (Department of Epidemiology Rollins School of Public Health Emory University), Dr. McAllister provided an overview the work completed by the Quality of Life/Patient Perspective Work Group.
He expressed the importance of QOL measurement and the need to include patients in the measure development process.
He summarized the Work Group’s findings and recommendations that address the need for greater patient education and satisfaction measurement through the application of three process-based measures and a pilot study.
He noted the Work Group’s decision to recommend specific QOL measurement tools, including the Short Form (SF-36) and KDQOL.
For a more detailed description of the work product, please see the Quality of Life/Patient Perspective Work Group Phase I Recommendations document.
Discussion of a Proposed Alliance Process – Kathy Lester, Patton Boggs LLP, Counsel to KCP
Kathy Lester of Patton Boggs described a proposed process that the Alliance could adopt for voting on recommendations.
She encouraged members to consider the process and to offer comments and recommendations about it. The process reflects those adopted by other quality initiatives.
Ms. Lester outlined one way to establish the formal voting process. Under this model, the designated representative from each Alliance member organization would be provided with a written ballot that identifies the issue(s) under consideration and the timing for the vote. No vote would occur during fewer than five (5) days.
She also outlined a proposal that would permit members to change a vote. She proposed an appeals process as well.
Ms. Lester articulated the steps of the process, beginning with the meeting and ending with the approval of a final set of quality measures. She requested that representatives take the documents back to their organizations, review the recommendations, and provide written comments to circulate to the Alliance.
She announced that there will be at least one conference call to discuss the measures, but advised Alliance members to contact kidney care specialists within KCP with specific questions or concerns. For additional information on the process or the content, Ms. Lester directed Alliance members to the website www.kidneycarepartners.org
Next Steps
Mr. Thiry urged Alliance members to use KCP as a resource throughout the process. He explained that while the Steering Committee will oversee the process and serve as a liaison between KCP, the work groups, and other Alliance members, everyone is welcomed to reach out to any other members of the Alliance.
He asked that all requests go through Kathy Lester (klester@pattonboggs.com/ 202.457.6562) and Linda Keegan (lkeegan@bgrdc.com/202-661-6326).
Mr. Thiry explained that the goal is to have a final vote on the recommendations discussed today at the end of October.
This means that there would be a call to discuss the recommendations and comments from Alliance members scheduled after Labor Day. The Administrator will contact members to schedule this call.
Preliminary Feedback
The new Alliance members expressed their optimism for the process and its openness. They supported the aim of the recommendations.
They offered the following initial comments about the recommendations:
- Some members suggested that there should be increased and improved physician reporting before implementing pay-for-performance measures.
- Other members suggested including a fact sheet that defines technical terms and conveys the clinical basis for each measures.
- One member expressed concern about the impact of pay-for-performance on minority communities and applauded efforts to ensure that cherrypicking does not occur.
Meeting adjourned just prior to 5:00 p.m.
