Table 4.

The ESRD PPS and QIP: Intended and potential unintended consequences

GoalsIntended EffectsTheoretical Unintended ConsequencesMonitoring and Alternative Options
CMS PPSDecrease costs for outpatient dialysis servicesPay less for the same level of careIncrease adverse clinical outcomes related to aspects of dialysis care provided for but not monitored by CMS, resulting in increased hospitalizations and higher overall costsMonitor transfusion rates
Minimize and control costs related to separately billable medications and servicesDecrease ESA use by eliminating incentive for useIncrease transfusions, which may effect kidney transplant immune sensitizationMonitor other meaningful patient outcomes
  Increase home dialysis modality useLimit physician prescribing abilities (via dialysis facility formularies restricted to medications for which the facility has negotiated a contract)Provide financial incentives for ESRD product development
  Reduce innovation and new product development for dialysis careMonitor changes in drug prescribing patterns
Limit “individualized” medical careIncrease comparative effectiveness research funding
Increase cherry picking of dialysis patients, creating access-to-care issues for sickest, most difficult to treat, or most vulnerable patientsMonitoring dialysis facility admission rates and withdrawals to determine patient access to care
Increase in overall cost of care for dialysis patients (e.g., hospitalizations)
Foster further consolidation in the dialysis market with smaller providers less able to negotiate favorable medication pricing
2012–2014 CMS QIPContain costsChange in practice patterns, including reduced ESA useIncrease transfusions, which may effect kidney transplant immune sensitizationReal-time monitoring of changes in transfusion rates, practice patterns, access to care, health disparities, hospitalizations, mortality
Improve care delivered to ESRD patients over timeIncrease arteriovenous fistula rates and reduce catheter ratesIncentivize practices that are not supported by clinical data, because it has never been prospectively demonstrated that achieving these clinical targets leads to improved clinically important patient outcomesSupport additional research on optimal ESA dosing and/or target hemoglobin level strategies in diverse dialysis populations
  Improve attention to patient perceptionsRestrict individualized medical careGenerate more evidence on optimal ESRD care by implementing a Children’s Oncology Group model, in which every patient is entered into a protocol to see which protocol produces better outcomes over time
Document infections in hemodialysisIncrease cherry picking of dialysis patients, creating access issues for sicker, more difficult to treat, or more vulnerable patients
Foster further consolidation in the dialysis market with smaller providers less able to absorb QIP payment withholds
  • CMS, Centers for Medicare and Medicaid Services; PPS, Prospective Payment System; QIP, Quality Incentive Program.