Letter from ANNA to the Centers for Medicare & Medicaid Services commenting on the proposed rule CMS-3206-P: Medicare Program; End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP)

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September 24, 2010

Donald M. Berwick, MD
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-3206-P
P.O. Box 8010
Baltimore, MD 21244-8010

Subject: CMS-3206-P: Medicare Program; End-Stage Renal Disease Quality Incentive Program

Dear Dr. Berwick:

The American Nephrology Nurses’ Association (ANNA) is pleased to comment on the proposed rule CMS-3206-P: Medicare Program; End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) issued by the Centers for Medicare and Medicaid Services (CMS) and published in the Federal Register on August 12, 2010.

Overview
The American Nephrology Nurses' Association (ANNA) is an organization of over 12,000 registered professional nurses who specialize in the care of individuals with kidney disease. The majority of the Association’s membership works in outpatient dialysis facilities. ANNA develops and updates standards of clinical practice, educates practitioners, stimulates and supports research, disseminates new ideas, promotes interdisciplinary communication and cooperation, and monitors and addresses issues affecting the practice of nephrology nursing.

ANNA recognizes that the changes legislated in the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) will have a major impact on the dialysis clinical practice environment, will affect nephrology nursing practice settings, and will also impact the patients we treat. Many of ANNA’s members have witnessed the benefits of the implementation of the inpatient prospective payment system and the improvements in care for transplant recipients. Transplant candidates, recipients, and living donors no longer spend weeks in the hospital before and after surgery, outcomes and surgical techniques have improved, and clinical and cost efficiencies have been gained in the process. We look forward to seeing similar benefits from the ESRD prospective payment system and the Quality Incentive Program.

ANNA supports the efforts of Congress and CMS to incentivize the provision of quality care in dialysis settings, which the Medicare Payment Advisory Commission (MedPAC) has recommended since early in this decade.

Comments on Proposed Rule
ANNA is a member of Kidney Care Partners (KCP), a broad alliance of members of the kidney care community. As an active and contributing member of KCP, ANNA endorses the comprehensive comments submitted by KCP on the QIP proposed rule. Our comments in this letter, however, serve to express our thoughts on the rule specifically from the nursing perspective. Nurses working in dialysis settings provide direct care to and spend more time with individuals on dialysis than any other group that will be commenting on this rule. As such, we have an important and unique perspective on aspects of the rule, and therefore, we hope CMS will carefully consider our recommendations.

ANNA reiterates KCP’s suggestion that CMS modify the proposed structure of the QIP by setting the maximum penalty at 1 percent and reducing the payment reduction increments to .25 percent. The 2 percent (maximum) penalty is far too stringent, especially since facilities will not have time to improve their respective performance scores because the proposed performance year will likely have ended by the time the QIP final rule is published. Therefore, we ask CMS to minimize the impact of the QIP in the first year of implementation because of the unintended consequences.

Beneficiaries receiving dialysis in poorer performing facilities are likely to become the unintended victims of decreased reimbursement to facilities (resulting in decreased income). Reductions in operating revenue inevitably will impact the number and mix of professionals and allied health personnel the facility can retain and may affect the ability of a provider or facility to continue providing care. Nurse staffing in outpatient dialysis settings is already at an historical low as a result of the nursing shortage and economic concerns. Dialysis facilities are facing increased financial constraints resulting from increased dependence upon public funding. We are concerned that quality of care in these facilities will decrease, due to the fact that there will be fewer, overburdened providers available to provide patient care.

Future Quality Measures
There have been numerous empirical studies published in the literature that have evaluated the importance of the role nurses play in ensuring quality healthcare. The work of nursing researchers and thought leaders such as Linda H. Aiken 1 have demonstrated through evidence-based research that nursing care has a significant impact on the quality of care provided to patients.

A study published in the March-April 2008 Nephrology Nursing Journal evaluated the connection between nursing and patient outcomes. The article stated the following:

This study provides empirical evidence that Registered Nurse (RN) staffing as well as the processes of care provided by RNs are essential to reducing the odds of adverse patient events in dialysis units. Therefore, in order to promote the health and safety of the growing numbers of patients with ESRD, policies and procedures at the federal, state, and dialysis organization levels must foster structures and processes of care in dialysis units that effectively utilize the invaluable skills and services of professional, registered nurses. 2

As the health professional responsible for providing the majority of hands-on care for individuals with ESRD, a successful and comprehensive quality incentive program must recognize the value of the nurse/patient relationship.

Thank you for your diligence in preparing this important proposed rule. ANNA looks forward to continuing to work with CMS during the implementation of the QIP. Please do not hesitate to contact me if ANNA can be of assistance.

Sincerely,

Donna Painter, MS, RN, CNN
President
American Nephrology Nurses’ Association

1 Aiken, L. H., Clarke, S.P., & Sloane, D.M. (2002). Hospital staffing, organization, and quality of care: Crossnational findings.

2 Thomas-Hawkins, Charlotte et al. (2008). Relationship Between Registered Nurse Staffing, Processes of Nursing Care, And Nurse-Reported Patient Outcomes in Chronic Hemodialysis Units, Nephrology Nursing Journal, 35, 123.