On Feb. 4, the Centers for Medicare and Medicaid Services released the rules of the long-awaited, renal-specific accountable care organization demonstration. The good news is that renal providers have some experience in working with an integrated kidney care model. In the late 1990s, CMS launched a managed care demonstration to determine if ESRD patients could have better outcomes. Kaiser and Blue Cross/Blue Shield of Florida were the participants; Kaiser's integrated care model proved more successful than Blue Cross, but patients in both plans did well with the extra benefits offered. In the early 2000s, Baxter-owned RMS Disease Management contracted with insurers to offer integrated care for ESRD patients. RMS employed case managers to provide a holistic team approach––not just to treat the kidney disease, but manage its underlying causes. In 2006, CMS initiated a five-year ESRD Management Demonstration. The goal of the demonstration was to study the impact of delivering integrated care to dialysis patients on clinical outcomes and Medicare costs. Participants Fresenius Medical Care and DaVita Inc. assumed the risk for the total cost of care for enrolled patients by receiving capitated risk-adjusted payments from CMS.

The goal for these efforts and the new renal ACO is to reduce the high cost of hospitalizations. Such costs consume almost 50% of the total ESRD payment bill each year. Can we spend that money on providing holistic patient care—better for the patient and better for the care team—and help the ESRD program reduce costs?

The renal ACO
There are several groups in the renal community that have been working hard to bring this ACO model to the surface: The Renal Physicians Association, which continually pushes to preserve the nephrologist's role at the head of the table for patient care and has been pushing for a integrated care model for the last three years; and dialysis providers Fresenius and DaVita, both with experience in capitated care models. Leaders from these organizations did not lose sight of the prize to bring this model to fruition.
The complete package is contained in a 53-page application that is due to the Centers for Medicare and Medicaid Services by May 1. The agency hopes to see 10-15 applications to get the demo started.

Rob Blaser, RPA's director of public policy, took some notes in his review of the application and at a open door forum held Feb. 5 by CMS:

  • The demo keeps payment for physicians outside the global payment.
  • CMS may expand beyond the 15 awards "if resources are available and a compelling reason exists to do so."
  • This iteration of the ACO model will remain at the current scope and will not be expanded.
  • "All participation appears to be tax ID number (TIN) based, so a physician practice could theoretically participate in multiple ESRD Seamless Care Organizations," wrote Blaser.
  • If a nephrology practice is already participating in a Medicare Shared savings program (MSSP) ACO, the individual physicians in that practice may participate in an ESCO under a separate TIN.
  • If a nephrology practice already has patients in a general MSSP ACO, those patients cannot currently be moved into a local ESCO, but they may be matched during the next new eligibility period.

Look for Blaser's complete review of the ACO model at www.renalmed.org. RPA is holding a session on integrated kidney care during its 2013 annual meeting March 14-17 in New Orleans. For a review of the program, click here.

Will an ACO work for small dialysis providers?
The ACO model creates some real challenges for small dialysis providers, who must be part of group that represents at least 500 patients. CMS said during the open door forum that 500 patients was the minimum needed to evaluate the success of the model. "Daunting," is the word one chief medical officer of a mid-sized dialysis organization used to describe the process.

It is important that small- and mid-sized dialysis providers have the ability to join in the ACO, because they are part of the future of care delivery for ESRD patients. Within that pool of 12-15 or so applications, we hope to see a variety of dialysis providers represented.

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