Providers skit­tish about Medi­care kid­ney-care ACO ini­tia­tive

Modern Healthcare - - NEWS - By Sabriya Rice

Kid­ney-care providers are rais­ing ques­tions about the pay­ment pro­vi­sions and qual­ity mea­sures to be used in a Medi­care ini­tia­tive sched­uled to start in Jan­uary that will test ac­count­able care mod­els for pa­tients with end-stage re­nal dis­ease. It’s not clear how many provider or­ga­ni­za­tions will de­cide to par­tic­i­pate, at least partly be­cause of th­ese con­cerns.

The CMS In­no­va­tion Cen­ter con­ceived the new Com­pre­hen­sive End-Stage Re­nal Dis­ease Care ini­tia­tive in Fe­bru­ary 2013 to test new pay­ment and de­liv­ery mod­els that would con­trol the costs of Medi­care’s end-stage re­nal dis­ease pro­gram, while en­cour­ag­ing bet­ter co­or­di­nated and more pa­tient-cen­tered care for its 507,000 ben­e­fi­cia­ries. Un­der that ini­tia­tive, the CMS is launch­ing end-stage re­nal dis­ease seam­less care or­ga­ni­za­tions, or ESCOs, for kid­ney fail­ure pa­tients, mod­eled af­ter ac­count­able care or­ga­ni­za­tions.

The CMS has not dis­closed how many ap­pli­ca­tions it has re­ceived from providers seek­ing to op­er­ate ESCOs, but some ob­servers sus­pect the num­ber is low. In re­sponse to stake­holder feed­back, the CMS ex­tended the ap­pli­ca­tion date. ESCOs that in­clude a large dial­y­sis or­ga­ni­za­tion were given un­til June 23 to sign up, while those with small dial­y­sis or­ga­ni­za­tions have un­til Sept. 15.

“It’s not likely go­ing to be the large num­ber of ap­pli­ca­tions they were hop­ing for,” said Dr. Ed­ward Jones, chair­man of Kid­ney Care Part­ners, a coali­tion of pa­tient ad­vo­cates, dial­y­sis pro­fes­sion­als, care providers and man­u­fac­tur­ers. Mem­bers of his coali­tion have ex­pressed con­cern about the CMS’ two-sided fi­nan­cial risk model, in which larger or­ga­ni­za­tions would be able to earn shared sav­ings but also face losses if cost and qual­ity tar­gets were not achieved. Smaller or­ga­ni­za­tions would not face losses.

DaVita Health­Care Part­ners, which along with Fre­se­nius Med­i­cal Care dom­i­nates dial­y­sis care in the U.S., hopes to op­er­ate as many as five ESCOs. “We re­ally be­lieve in care co­or­di­na­tion,” DaVita Chief Med­i­cal Of­fi­cer Dr. Allen Nis­senson said in a re­cent in­ter­view. “We want to be held ac­count­able for the out­comes, as well as for the cost.”

But DaVita and other providers re­main crit­i­cal of how the CMS has im­ple­mented the pro­gram. “The eco­nom­ics are not great, the qual­ity tar­gets are not known and they haven’t told us what in­ter­ven­tions are go­ing to be dic­tated by the waivers,” said Robert Sepucha, vice pres­i­dent of cor­po­rate af­fairs for Fre­se­nius, which has sub­mit­ted six ap­pli­ca­tions.

An­other con­cern is that the pro­gram’s waivers won’t give providers enough lee­way to try new in­ter­ven­tions that are pro­hib­ited un­der tra­di­tional Medi­care re­im­burse­ment, such as of­fer­ing low-in­come pa­tients free trans­porta­tion to the dial­y­sis clinic.

The qual­ity met­rics ap­plied to this pa­tient pop­u­la­tion have to be spe­cific, Jones said, be­cause dial­y­sis pa­tients tend to have mul­ti­ple chronic dis­eases and face dif­fi­cult and costly treat­ments. “The prob­lem is, very few of the qual­ity mea­sures have been field-tested, and some are tested in the gen­eral pop­u­la­tion but not in the dial­y­sis pop­u­la­tion,” he added.

In re­sponse, the CMS said it al­ready has pub­lished a pre­lim­i­nary set of qual­ity mea­sures cov­er­ing dis­ease man­age­ment, qual­ity of life, mor­tal­ity rates, and hos­pi­tal­iza­tion and read­mis­sion rates. It ex­pects to re­lease fi­nal de­tails on its qual­ity-mea­sure­ment strat­egy by late fall. Par­tic­i­pants can ex­pect “sub­stan­tial over­lap” between the pre­lim­i­nary and fi­nal qual­ity mea­sures, the agency added.

The treat­ment of end-stage re­nal dis­ease cost Medi­care $34 bil­lion in 2011, about 6% of all Medi­care spend­ing. He­modial­y­sis for end-stage re­nal dis­ease costs the pro­gram about $88,000 an­nu­ally per pa­tient.

The CMS ini­tia­tive drew early crit­i­cism from kid­ney re­searchers, who sup­ported the ESCO con­cept but ques­tioned why it wouldn’t also tar­get pa­tients in ear­lier stages of kid­ney dis­ease to slow its pro­gres­sion and pre­vent end-stage dis­ease re­quir­ing dial­y­sis.

DaVita’s Nis­senson echoed other ex­perts’ reser­va­tions about the model. “It’s sort of sad that the full po­ten­tial prob­a­bly won’t be re­al­ized,” he said.

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