Full po­ten­tial of Medi­care kid­ney-care ACOS ‘won’t be re­al­ized’

Modern Healthcare - - Q&A -

“It’s crit­i­cal to move up­stream and start look­ing at chronic kid­ney dis­ease pa­tients be­fore they reach end-stage dis­ease.”

Dr. Allen Nis­senson has been chief med­i­cal of­fi­cer for Den­ver-based DaVita Kid­ney Care, a divi­sion of DaVita Health­Care Part­ners, since 2008. DaVita Kid­ney Care has more than 2,000 out­pa­tient dial­y­sis cen­ters in 46 states and is one of the largest dial­y­sis providers in the U.S. Nis­senson for­merly served as as­so­ciate dean and direc­tor of the dial­y­sis pro­gram at the David Gef­fen School of Medicine at UCLA, and as pres­i­dent of the Re­nal Physi­cians As­so­ci­a­tion. Be­fore that, he served as a Robert Wood John­son health pol­icy fel­low of the In­sti­tute of Medicine, work­ing with the late Sen. Paul Well­stone. Mod­ern Health­care edi­tor Mer­rill Goozner re­cently spoke with Nis­senson. This is an edited tran­script.

Mod­ern Health­care: How are dial­y­sis pa­tients far­ing to­day?

Dr. Allen Nis­senson: If you look at the out­comes for all U.S. pa­tients over the past decade, they’ve im­proved sig­nif­i­cantly. The pa­tients are still re­ally sick but sur­vival is bet­ter. They’re in the hos­pi­tal less and they’re gen­er­ally health­ier.

MH: How have Medi­care pay­ment changes for end-stage re­nal dis­ease, specif­i­cally go­ing to a bun­dled pay­ment sys­tem, af­fected DaVita?

Nis­senson: The prob­lem is, Medi­care pay­ment is not equal to the cost of the treat­ment, so for the 85% of pa­tients we treat who de­pend on Medi­care, we lose money on ev­ery treat­ment. That only works be­cause the 10% of pa­tients who have pri­vate in­sur­ance sub­si­dize all of the oth­ers.

MH: In 2012, DaVita ac­quired Los An­ge­les-based Health­Care Part­ners. Yet the deal hasn’t paid off in the short run. What’s hap­pen­ing?

Nis­senson: The rea­son we ac­quired HCP is that their vi­sion of health­care for the broader Amer­i­can pop­u­la­tion is ex­actly our vi­sion for kid­ney pa­tients. We’ve got to fig­ure out a way to take the cur­rent frag­mented sys­tem and co­or­di­nate it. In the short term, HCP is not thriv­ing to the ex­tent we’d like it to.

Health­Care Part­ners was a physi­cian-led, physi­cian-fo­cused or­ga­ni­za­tion. Nat­u­rally there’s some ten­sion there. So we’re in the process of fig­ur­ing out how do we take the best of Health­Care Part­ners and the best of DaVita, with its busi­ness dis­ci­pline and or­ga­ni­za­tional skills, and bring these two to­gether.

MH: How do you see work­ing with chronic kid­ney dis­ease pa­tients served by HCP?

Nis­senson: It’s crit­i­cal to move up­stream and start look­ing at chronic kid­ney dis­ease (CKD) pa­tients be­fore they reach end-stage dis­ease. Health­Care Part­ners has thou­sands of CKD pa­tients. We have a pro­gram called Kid­ney Smart, which is a CKD ed­u­ca­tional pro­gram di­rected at pri­mary-care doc­tors and pa­tients, that we are in­tro­duc­ing in South­ern Cal­i­for­nia in HCP. The up­stream work is re­ally go­ing to pay off in the long run.

MH: The Medi­care In­no­va­tion Cen­ter is com­ing out with pi­lots to co­or­di­nate care for end­stage re­nal dis­ease pa­tients, called ESRD Seam­less Care Or­ga­ni­za­tions. How do you plan to par­tic­i­pate in ESCO pi­lots?

Nis­senson: We’re hop­ing to do any­where from two to five of them. We haven’t heard yet if we’ve been se­lected to do that many, but we’re con­fi­dent we’ll do some. We re­ally be­lieve in the ac­count­able care or­ga­ni­za­tion ap­proach. We would have liked to do this much more broadly. But there are some is­sues around the way the fi­nanc­ing is done and other im­por­tant is­sues in terms of the reg­u­la­tions. We’re en­thused but kind of sad that the full po­ten­tial prob­a­bly won’t be re­al­ized.

MH: Be­fore CKD pa­tients wind up in dial­y­sis, they usu­ally are cov­ered by pri­vate in­sur­ance. But once they are on dial­y­sis, they’re cov­ered by Medi­care. What can be done to co­or­di­nate care across these two pay­ers?

Nis­senson: There’s no ques­tion this is a prob­lem. When you go on dial­y­sis, your pri­vate in­sur­ance re­mains the pri­mary payer for 30 months. Be­cause of the in­ad­e­quacy of the Medi­care pay­ment, that gives us 30 months work­ing with the com­mer­cial payer so it can help us cover the cost of the Medi­care pa­tients. The whole re­nal care com­mu­nity has been try­ing to get the CMS to ex­tend that pe­riod, so that com­mer­cial in­sur­ance will be the pri­mary payer for a longer pe­riod. In the past, pri­vate in­sur­ers were against it be­cause they said they’d be stuck with these re­ally sick pa­tients for longer. What they found is, if they col­lab­o­rate on care co­or­di­na­tion, their to­tal costs of care ac­tu­ally go down. So now even the pri­vate in­sur­ers aren’t against it. We’re work­ing very hard to get Medi­care to ex­tend this, which we think would help ev­ery­body.

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