Baseline and Performance

ESRD Quality Incentive Program (QIP)

The ESRD QIP scores facilities on their performance during each calendar year according to the measures established for the relevant payment year. For clinical measures, CMS applies two scoring methods: achievement (comparing facility performance to a set of values derived from all facilities nationally) and improvement (comparing facility performance to the facility’s individual performance during the prior year). For reporting measures, CMS assigns points based on whether a facility provided the required data during the calendar year.

The baseline periods are the designated time (often a full year) during which data is gathered from all dialysis facilities. That information will serve as the basis to evaluate a facility’s future performance. In other words, data collected during the comparison periods is used to create performance standards.

CMS compiles national performance data during the achievement baseline period to calculate achievement thresholds, performance standards, and benchmarks. CMS uses a facility’s own data during the improvement baseline period to establish the improvement threshold.

The actual performance period (which usually covers a full year as well) follows the comparison period. Immediately following the completion of the performance period, CMS assesses the facility’s performance and calculates a score for each measure, according to the method detailed each year in a final rule published in the Federal Register. Scores for each measure are then combined to create the Total Performance Score for each facility.  If a facility’s Total Performance Score does not meet or exceed the performance standards established during the earlier comparison period, then it will incur payment reductions of up to two percent for the entire PY.

The following chart associates selected ESRD QIP payment years with the respective performance period, achievement comparison period, improvement comparison period, and any exceptions that apply.

Payment Year Performance Period Achievement Baseline Period Improvement Baseline Period Exceptions
PY 2017 1/1/2015 – 12/31/2015 1/1/2013 – 12/31/2013 1/1/2014 – 12/31/2014 NHSN Bloodstream Infection clinical measure uses 2014 for both Achievement and Improvement
PY 2018 1/1/2016 – 12/31/2016 1/1/2014 – 12/31/2014 1/1/2015 – 12/31/2015 ICH CAHPS clinical measure uses 2015 for both Achievement and Improvement
PY 2019 1/1/2017 – 12/31/2017 1/1/2015 – 12/31/2015 1/1/2016 – 12/31/2016 None
PY 2020 1/1/2018 – 12/31/2018 1/1/2016 – 12/31/2016 1/1/2017 – 12/31/2017 NHSN HCP reporting measure uses “flu season” of 10/1/2017 – 3/31/2018

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