In the U.S. kidney policy world, one of the most noteworthy and controversial events of recent months was the introduction of S. 3090/H.R.5942:: the Dialysis Patient Access to Integrated-care, Empowerment, Nephrologists, Treatment, and Services Demonstration Act of 2016 (aka, the PATIENTS Act). Briefly, the bill seeks to establish an ESRD-specific model of coordinated care not unlike that of the ESRD Seamless Care Organizations (ESCOs), which begins year two of implementation in 2017, but differing on several fronts, including less restrictive geographic requirements and more flexible partnership requirements.

Continually improving ESRD patient care coordination should be a high priority goal for all stakeholders in the kidney care community and the Renal Physicians Association strongly believes that conceptually this legislation has significant merit. As currently written, if enacted, this bill would: 1) expand access to improved care coordination for enrolled patients; 2) give enrolled patients supplemental benefits beyond what is available under current Medicare plans; 3) offer more flexible partnership options for nephrologists as part of the created entity; 4) establish incentives for providers, physicians, and patients in the model; and 5) in the context of  the Medicare Access and CHIP Reauthorization Act (MACRA), these entities would be legislatively mandated to be Advanced Alternate Payment Models (APMs). As a result, nephrologists who are APM qualified participants would be eligible for the 5% payment bonus and not required to comply with MIPS reporting requirements.

Read more: Integrated care bill divides renal community 

RPA’s concerns with the bill include the lack of a defined nephrologist role in a formal governance structure for the model, the limited attention given to transplantation issues, the transition of pediatric patients to adult care, and the use of the term “medical home” to describe the model.  Additional concerns include the provision that requires patients to opt-out of the program rather than allowing them to opt-in, and the absence of the patient voice in the development and structure of the model. 

The controversy surrounding the PATIENTS Act emanates in part from sentiment that the bill structurally favors the large dialysis organizations that have the capacity and infrastructure to successfully implement such a model. However, given the challenges facing the specialty pertaining to workforce and the simple viability of nephrology practice, reasonable access to participation in an APM could be a critically important factor to the future success of the discipline.

RPA’s concerns over the bill were presented in correspondence to the original sponsors of the legislation, in which RPA neither endorsed nor opposed the bill (as was indicated in a recent article on the issue). We believe that while the fine print on legislation such as the PATIENTS Act should always be carefully scrutinized (and that this scrutiny will often identify issues that require resolution before endorsement, such as those outlined above), innovative efforts to improve care should not be summarily shut down. And while RPA will not be endorsing the legislation until the issues outlined above are addressed (particularly regarding the nephrologists’ role in governance and the status of patient candidates for transplantation), RPA considers the PATIENTS Act to be a work in progress and remains open to the potential for supporting the bill if these issues can be resolved.