30 E. 33rd Street
New York, NY 10016
Tel 212.889.2210
Fax 212.689.9261
www.kidney.org
August 21, 2014
Patrick Conway, M.D.
Chief Medical Officer and Director
Center for Clinical Standers and Quality
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244
Re: Dialysis Five Star Program
Dear Dr. Conway,
The National Kidney Foundation is very concerned about the roll out of the Dialysis Five Star program
under its current design. While our online survey of dialysis patients and their loved ones indicated that
few patients use Dialysis Facility Compare (DFC) to make decisions about where they receive dialysis,
(most patients chose their dialysis facility based upon the recommendation of their nephrology
practitioner and/or proximity of the facility to their home), we think the five star program has great
potential to increase use of DFC by patients and families. This is particularly important as internet and
smart phone application use becomes widespread by people looking to see how restaurants, movies,
home improvement companies, and more all rate with consumers and critics. NKF is supportive of
applying a five star rating program to dialysis facilities in order to better inform patients and their loved
ones about the quality of care delivered at facilities across the country, but we do not think the program
as currently designed accomplishes that goal. We urge the agency to incorporate needed improvements
before publicly rolling out the program and offer the following suggestions.
Differentiation between facilities and driving improvement
While we respect the agency’s intent to provide comparable information to beneficiaries so they can
better differentiate between dialysis facilities, we do not think using a bell curve is appropriate. First, it
provides misleading information because statistically insignificant differences in performance between
facilities could result in one facility having fewer stars than another. In addition, it does not achieve the
agency’s goal of driving improvement. A bell curve will always keep some facilities with a rating of 1-2
stars and the majority of facilities will receive average scores (3 stars). If the majority of facilities improve
(which would be the desired effect) the curve would simply shift, making it impossible for most facilities to
achieve a better score. This is unlikely to create much incentive for facilities with 3-4 stars to try and
achieve a higher rating.
National Kidney Foundation
30 E. 33rd Street
New York, NY 10016
Tel 212.889.2210
Fax 212.689.9261
www.kidney.org
As an alternative we suggest establishment of a benchmark that measures achievement and
improvement, similar to the ESRD Quality Incentive Program (QIP). When we surveyed patients on how
they thought facilities should be rated, 66.5% stated they believed facilities should be awarded stars
based on their individual performance and not compared directly with facilities nationally or regionally.
Establishing a benchmark is a more appropriate reflection of individual facility performance than grading
on a curve, and thus more useful to patients and their loved ones.
In addition, there are other ways to differentiate between facilities on factors important to patients. For
example, DFC already provides information on what modalities are available at the facility, whether the
facility offers evening shifts, and the size of the facility. While not factored into a star rating, these are
features that a patient will consider when evaluating where to receive dialysis.
Standardized ratio measures need to be adjusted
Another problem that is exacerbated by a bell curve methodology is the use of standardized ratios that
are not stratified by causes related to ESRD and have not been evaluated for combinations of
socioeconomic status (SES) and demographic factors (such as geographic location, race, age, sex) known
to influence health disparities. Therefore, it is possible that differential ratings of facilities may be a
reflection of population health and not a reflection of the quality of care delivered in the facility. While we
know it is against current CMS policy to adjust for socioeconomic status (SES), we appreciate that CMS
evaluated certain demographic factors to determine if each contributed to differences in the Standardized
Hospital Admissions Ratio (SHR), Standardized Mortality Ratio (SMR), and the Standardized Blood
Transfusion Ratio (STR). We also agree that adjusting the SMR for race, as the agency has done, is
appropriate as evidence shows African Americans with kidney failure have a higher incidence of death
across the board and this is not unique to dialysis facility performance. However, we believe an evaluation
of the combination effects of demographics and SES is needed, before rolling out the dialysis five star
program, to ensure patients are seeing a true reflection of facility performance on the measures and not
an assessment of the population health.
While facilities should be encouraged to employ strategies to improve outcomes for patients even in the
face of known factors that contribute to poor health, we do not think facilities working hard to improve
outcomes for more disadvantaged patients should be given a lower star rating because of innate factors
that prevent them from achieving the same outcomes as a facility that treats patients where health
disparities are not as prevalent. These facilities should be encouraged to improve upon the health of their
patients, which is another reason NKF recommends that facility improvement on the measures be
incorporated into the methodology for star ratings. We believe giving underperforming dialysis facilities
the ability to increase the number of stars they receive creates an incentive for average and
underperformers to target interventions specific to their patient population to improve outcomes.
National Kidney Foundation
30 E. 33rd Street
New York, NY 10016
Tel 212.889.2210
Fax 212.689.9261
www.kidney.org
Factors patients care about
In a survey of dialysis patients and their loved ones we found that over 80 percent of patients stated the
single most important factor they used to judge the quality of care patients receive was how attentive the
dialysis facility staff was to them. We believe allowing patients’ experience with their care to be reflected
in the star ratings from the beginning is the best way for CMS to accomplish its goal to “report what is
most important to patients in a way they can understand.” As an example an article published in the
Gerontologist (May 2014), the journal of the American Society of Gerontology, showed that, for patients in
Ohio, satisfaction with nursing home care was not aligned with performance on the star ratings.
The In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) is
one mechanism that could be incorporated into the five star ratings. However, we also recommend that
CMS provide a way for patients and their loved ones to directly contribute to the dialysis facility star
ratings website. This could be accomplished by allowing patients and their loved ones to award stars and
issue comments based on how they assess the quality of the facility. CMS could establish a way to verify
that commenters are really patients or their loved ones, but ensure this information is kept confidential.
For example, patients or a loved one could be required to log into the system when commenting with
their Medicare ID number. This approach would allow them to interact with the DFC star ratings website
in a manner similar to how consumers interact with websites like Yelp and Rotten Tomatoes. On Rotten
Tomatoes, consumers see both the critics’ review and the audience’s review; a similar strategy could be
used on the dialysis five star site.
In sum, NKF believes CMS should make changes to the star ratings, prior to roll out, that judge dialysis
facilities on absolute benchmarks, factor in facility improvement on performance, assess and, if necessary,
appropriately adjust the standardized ratio measures for combination factors of SES and demographics,
and incorporate patient satisfaction. We think it’s important that the program rolled out is a fair and
accurate portrayal of the quality of care delivered in the dialysis facility and that it incorporates patients’
values and satisfaction from the beginning. We are concerned that a premature launch will only result in
misperceptions and potentially public mistrust in the value of the system, which would undermine the
goals of the program.
NKF has been engaging kidney patients in education, science, research, and advocacy for over 60 years.
We share the agency’s goals in better empowering patients to make informed decisions about their care
and we would like the opportunity to work closely with you on further improving and testing the five star
program with patients prior to launch in order ensure its success.
Sincerely,
Kerry Willis, PhD
Senior Vice President for Health Science and Education