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Report (OEI-01-11-00550)

The ESRD Beneficiary Grievance Process

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Over 5,000 dialysis facilities provide life-sustaining treatment to more than 340,000 End-Stage Renal Disease (ESRD) Medicare beneficiaries. Medicare regulations require that dialysis facilities implement a process for beneficiaries to file grievances without reprisal or denial of services. Beneficiaries also have the option of filing grievances with ESRD Network Organizations (networks), which are Medicare contractors that oversee dialysis facilities. Previous OIG work found that the ESRD beneficiary grievance process was unreliable in identifying and resolving quality-of-care concerns.


We sent a questionnaire to a random sample of 150 dialysis facilities and received an 80-percent response rate. We sent a questionnaire to 17 of the 18 networks and received a 100-percent response rate. (We conducted a site visit to the 18th network, during which we pretested the questionnaire.) We also made site visits to 13 facilities and 3 networks in 5 States, where we conducted structured interviews with staff and reviewed documentation, including the facility grievance logs.


Dialysis facilities have latitude in what they record as a grievance, and two-thirds of facilities recorded five or fewer grievances in 2011. The most common grievances recorded concerned the comfort or appearance of the physical environment and interactions with staff. Anonymous grievance processes can be difficult to implement, and fear of reprisal may be difficult for facilities to measure. CMS has begun to require that facilities use a standardized satisfaction survey that does not assess patient fear of reprisal for filing a grievance. ESRD networks' involvement with beneficiary grievances are constrained by limited data and reporting. They analyze grievances for trends, but the database they use is of limited utility. CMS is unable to readily provide network grievance and complaint data.


We recommend that CMS (1) define "grievance" for facilities, (2) require that facilities report grievances regularly to their respective networks, (3) provide guidance to facilities on what constitutes a robust process for anonymous grievances, (4) work with the Agency for Healthcare Research and Quality to add a question to the standardized satisfaction survey to assess ESRD beneficiaries' fear of reprisal, and (5) provide networks with better technical support for their grievance database. CMS concurred with three of our five recommendations.

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