Early winners and losers in dialysis center pay-for-performance

BACKGROUND We examined the association of dialysis facility characteristics with payment reductions and change in clinical performance measures during the first year of the United States Centers for Medicare & Medicaid Services (CMS) End Stage Renal Disease Quality Incentive Plan (ESRD QIP) to determine its potential impact on quality and disparities in dialysis care. METHODS We linked the 2012 ESRD QIP Facility Performance File to the 2007-2011 American Community Survey by zip code and dichotomized the QIP total performance scores-derived from percent of patients with urea reduction rate > 65, hemoglobin < 10 g/dL, and hemoglobin > 12 g/dL-as 'any' versus 'no' payment reduction. We characterized associations between payment reduction and dialysis facility characteristics and neighborhood demographics, and examined changes in facility outcomes between 2007 and 2010. RESULTS In multivariable analysis, facilities with any payment reduction were more likely to have longer operation (OR 1.03 per year), a medium or large number of stations (OR 1.31 and OR 1.42, respectively), and a larger proportion of African Americans (OR 1.25, highest versus lowest quartile), all p < 0.05. Most improvement in clinical performance was due to reduced overtreatment of anemia, a decline in the percentage of patients with hemoglobin ≥ 12 g/dL; for-profits and facilities in African American neighborhoods had the greatest reduction. CONCLUSIONS In the first year of CMS pay-for-performance, most clinical improvement was due to reduced overtreatment of anemia. Facilities in African American neighborhoods were more likely to receive a payment reduction, despite their large decline in anemia overtreatment.