Evaluation of the Impact of the End Stage Renal Disease Quality Incentive Program on the Elderly



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As Medicare expenditures continue to increase, pay-for-performance programs have been implemented to curb costs and improve the quality of care. As the first federally mandated pay-for-performance program, the End Stage Renal Disease Quality Incentive Program links a portion of payment to a dialysis facility’s performance on pre-established quality measures. More accurately described as a penalty program, the QIP does not provide financial rewards for attaining high scores on performance measures. The maximum payment reduction which Medicare can apply to any facility is two percent. Concerns about the effectiveness of the incentive program since its implementation in 2012 have been expressed. While the financial incentive is aimed to change provider behavior in order to generate patient health improvements and cost reductions, these outcomes have been questionable. Provider interventions are not easily attributable to patients’ achieving the targeted measures, and unintended consequences of the incentive program are a challenge. For elderly dialysis patients, who experience different physiological changes and treatment goals than their younger counterparts, the incentive program may not be responsive to their individual needs and lead to unwanted outcomes. This dissertation describes the development and impact of the End Stage Renal Disease Quality Incentive Program (ESRD QIP), a federally funded initiative to cost effectively improve delivery of patient care and patient health outcomes. An introductory first chapter chronicling the history of the ESRD program leading to its current status will be followed by the second chapter, which include the research questions and hypotheses. The third chapter is a systematic review, which synthesizes the available literature on the status of the ESRD QIP. Chapters 4 and 5 empirically examine longitudinal data of dialysis patients, facilities and neighborhood characteristics since the implementation of the ESRD QIP. Chapter 4 evaluates high and low scoring dialysis facilities, while Chapter 5 assesses patient health outcomes for ESRD QIP targeted and non-targeted measures. Chapter 6 discusses the principal findings and a critical discussion of the results. The dissertation will conclude with Chapter 7, which consists of the study significance, limitations and policy implications.