BALTIMORE – When no one comes to the party, it may be time to rewrite the invitation.

In this case, the Centers for Medicare & Medicaid Services’ Innovation Center is getting ready to re-launch its request for application, or RFA, for the Comprehensive ESRD Care Model demonstration. The Innovative Center’s leader Patrick Conway, MD, MSc, said he hopes that the changes they made, based on criticisms from the renal community, would bring more dialysis providers to the table.

“We have done the work,” said Conway, who gave the Louis Diamond Lecture during the Renal Physicians Association annual meeting here. “Hopefully in the next month we will get it out.” The lecture was part of a four-day program marking the RPA’s 40th anniversary. Conway, a pediatrician with a long employment history at CMS and other agencies looking at improving outcomes, took over for nephrologist Barry Straube as CMO for CMS in August 2011.

'Please, please apply…'
CMS pulled the plug on the Accountable Care Organization-type demonstration’s January launch after numerous extensions for applications failed to produce the 10-12 viable candidates the agency was seeking. The project puts dialysis providers and nephrologists in charge of coordinating care for ESRD patients (who are pre-selected by CMS from the provider’s service area). These partnerships between providers and nephrologists would include other specialists and local hospitals to form an ESRD Seamless Care Organization, or ESCO, to help coordinate care for the enrolled ESRD patients. 

(Related: MedPAC report recommends no increase in dialysis facility payment)

But dialysis providers have complained that the rules of the demonstration place too much risk and expense in their hands, while questioning the likelihood about potential rewards. If costs of care are reduced—based on what Medicare had historically paid for caring for patients enrolled in the demonstration—the ESCO and Medicare would share in the savings.

Major issues with the RFA
Dialysis organizations have cited several problems with the RFA developed by CMS:

  • a rebasing of the cost per patient after the first three years of the demonstration, which will ultimately reduce the savings in the last two years and give the ESCOs a lower return to cover their operational costs
  • no incentive to refer patients to transplant; younger patients who might make good candidates for transplant will be leaders in reducing health care costs within the demonstration. Providers may be reluctant to “lose” them because it will reduce the ESCO’s savings
  • a demonstration rule restricting physicians who have joint venture agreements with dialysis providers to participate as partners in the ESCO

Conway said CMS sought feedback on problems with the RFA by sitting down with dialysis providers interested in the demonstration and asking questions as to why they didn’t apply. That feedback was incorporated in the new application, he said.

“We have tried to make an array of adjustments” to make the application more amenable," he said. “This is a critical population; we think it (the demonstration) has some value.”

Changing how to pay for care
Like Straube, Conway continues to push the agency’s shift from fee-for-service medicine to value-based purchasing that can generate improved outcomes. CMS helps fund more than 350 ACOs with five million Medicare beneficiaries (about 10% of the population). He said approaches that included shared savings between payer and health care provider and aligning incentives means patient care is managed more holistically, instead of just treating a particular disease. Care coordination will play a crucial role. “I’ve seen the power of collaboration” in pediatric care, Conway said.

That may lead to nephrologists playing a bigger role in primary care—not just treating kidney failure but all the medical conditions that commonly follow.  Doing so requires physicians to have a stronger knowledge based of managing multiple tasks, including understanding how to run their practices. Conway agreed that medical schools are doing an inadequate job of providing physicians with the business tools they need. “More clinicians need that type of training,” Conway said.

More coverage from the RPA Annual Meeting

RPA director of public policy: We are close to SGR reform