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Reform Update: Providers still skittish of CMS' renal ACO initiative

With just a few months before its launch, some providers are expressing frustration with a CMS initiative aimed at testing innovative payment and care-delivery models specifically geared toward patients with end-stage renal disease. Too many questions remain about key details and the framework offers too little potential for success.

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

The CMS Innovation Center conceived the new Comprehensive End-Stage Renal Disease Care initiative, or CEC, in February 2013 to investigate new payment and delivery models that would rein in those costs while encouraging higher quality, better coordinated and more patient-centered care for these more than 500,000 beneficiaries.

Introducing a model similar to the accountable care organizations aimed at improving the efficiency and quality of care for the general Medicare population, the CMS is establishing ESRD seamless care organizations, or ESCOs, for kidney failure patients.

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The initiative drew early criticism from kidney researchers, who supported the idea but questioned why the ESCO model wouldn't also target patients in earlier stages of the disease to slow its progression. They also expressed reservations about how the CMS would calibrate the quality targets.

Questions about the details of the program persist more than a year and a half later, even though the CMS is expected to begin testing accepted models in January 2015.

“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 Medical Care, a dialysis service provider that has submitted about six applications to the program.

The quality metrics applied to this patient population have to be specific, he said, because they tend to have multiple chronic diseases and face difficult and costly treatments.

Another fear is that the program's waivers won't give providers enough leeway to try new interventions that are prohibited under traditional Medicare reimbursement, Sepucha said. For example, offering financially strapped patients free transportation to a dialysis clinic is considered essentially a kickback to the patient. If an approach is denied “We'll have to scratch our heads and go back to the drawing board,” Sepucha said.

In response to such criticisms, the CMS says similar models, such as the Pioneer ACO payment model and the Comprehensive Primary Care Initiative, were able to successfully ramp up their care-management activities well before the quality metrics were finalized. The CMS also says the agency has already published a set of preliminary CEC measures. The list includes metrics for quality of life, disease management (like extremity amputation), mortality rates and care coordination (like readmission and hospitalization ratios). The CMS expects to release details on the quality measurement strategy for the initiative in late fall of this year. Participants can expect “substantial overlap” between the preliminary and final list when it is released in the late fall, the CMS said.

“The problem is very few of the quality measures have been field-tested, and some are tested in the general population but not the dialysis population,” says Dr. Edward Jones, chairman of Kidney Care Partners, a coalition of patient advocates, dialysis professionals, care providers and manufacturers. “They've been put out by technical expert panels of CMS, with little input from the community,” he said.

The CMS has not disclosed the number of applications it has received from providers vying to operate as ESCOs, but some observers suspect the numbers are low. In response to stakeholder feedback, the CMS extended the application date this past spring. ESCOs that include a large dialysis organization were given through June 23, 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 Jones, who is also a practicing nephrologist in the Philadelphia area. Members of the coalition also expressed concern over a two-sided risk model, in which larger organizations who participate would not only suffer losses if targets are not reached, but would also have to pay back the federal agency for money lost. Many support the CMS efforts, “but it has to be done the right way,” Jones said.

Other payment and delivery experiments the CMS has launched under the Patient Protection and Affordable Care Act have yielded mixed results so far. Last January, the first results for Medicare's shared-savings program for ACOs showed uneven progress among hospitals and physicians. The Innovation Center's Pioneer ACO Model, meanwhile, saw nine of 32 organizations exit the program after its first year. Several of them switched to the less financially risky shared-savings program.

Kidney Care Partners—whose members include AbbVie, the American Kidney Fund, the American Society of Nephrology and DaVita HealthCare Partners—is supporting legislation it says will lay the groundwork for the success of programs like Medicare's new ESRD initiative. The Chronic Kidney Disease Improvement in Research and Treatment Act of 2014 bill aims to address gaps in kidney disease research, drive efforts to improve education for patients, and establish an interagency committee to improve research coordination.

For now, potential participants in the CEC remain skeptical. The way in which the model has been rolled out has provided little incentive, kidney-care providers say.

DaVita, which along with Fresenius dominates dialysis care in the U.S., is hoping to have as many as five ESCOs accepted by the CMS.

“We really believe in care coordination,” DaVita Chief Medical Officer Dr. Allen Nissenson said in a recent interview with Modern Healthcare. “We want to be held accountable for the outcomes as well as for the cost. We've asked for that.”

But he also echoed Sepucha's reservations about the model. “It's sort of sad,” Nissenson said, “that the full potential probably won't be realized.”

October ruling expected in Fla. Medicaid case

A federal judge is expected to rule in October on a class-action lawsuit filed in 2005 against Florida health and child-welfare officials. The case claimed the state violated federal law by providing inadequate Medicaid services to children, and that care of the children had been hampered by low Medicaid payments to doctors, the Miami Herald reported last week. According to the report, if the judge rules in favor of the plaintiffs, the state might have to come up with about $227 million a year to permanently increase payment rates to pediatricians and dentists, pending any appeals.

Follow Sabriya Rice on Twitter: @MHSRice



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