Legislation introduced in Congress earlier this year (H.R. 5942, H.R. 5506 and S. 3090), would establish a 5-year voluntary Medicare demonstration model to integrate care for patients with end-stage renal disease (ESRD). This is separate from, and in addition to, the current ESRD Seamless Care Organization (ESCO) model that the Centers for Medicare & Medicaid Services (CMS) Innovation Center has been running since October 2015. The Dialysis PATIENTS Demonstration Act would allow Medicare-eligible dialysis providers to set up independent, integrated care networks.
DCI is fully committed to the development of new comprehensive and innovative care models for patients with kidney disease. But there are five key reasons we oppose the DPDA.
- Limitations for small providers. The legislation requires that organizations must have sufficient capital reserves and be able to bear risk. Only the largest dialysis providers could independently implement the DPDA model, and we are concerned that it would increase the risk of further consolidation in our industry. Patient care improves when a multitude of providers develop different innovative models and share these unique interventions. Policymakers should be careful not to inhibit this critical industry dynamic.
- Limited options for patients. We are concerned about the lack of patient protections, including automatic enrollment in the DPDA and the risk that a patient could be in a closed network with limited provider choices. Specifically, Medicare patients would be assigned to an organization and have just 75 days to opt-out. After that, ESRD patients would have only one opportunity annually to exit the demonstration. After the first year, patients would have the option to enroll in the organization’s closed network or stay in the open network. If one chooses the closed network, a patient’s choice of providers may become restricted. In the open network, costs may be higher. More broadly, we are concerned that by inhibiting smaller providers’ ability to compete on a level playing field with the largest providers, the DPDA could have the unintended effect of further limiting patient choice.
- No inclusion of CKD care, transplant. This model is for ESRD patients only and does not provide care or financial incentive for chronic kidney disease (CKD) education/care, kidney transplant, and hospice care.
- DPDA does not require nephrologist ownership. We see the nephrologist as the “captain of the ship,” leading the care for patients on dialysis or with advanced kidney disease. At DCI, we currently have 48 nephrologist owners across our three ESCOs and have made great strides working with them as equal partners to improve care for our patients.
- Model of care for the DPDA too narrow. Unlike the ESCO, where end-of-life care is explicitly included, a patient is dropped from the DPDA if that patient selects hospice care. Currently few patients on dialysis benefit from hospice care and as a result many die in the hospital instead of at home. According to a recent study, 32.3% of patients on dialysis die in the ICU, compared to 13.4% of patients with cancer and 8.9% of patients with dementia. Our patients deserve better. We are concerned that a patient in the DPDA would be less likely to choose a smooth transition to end of life because she will lose her expanded clinical team once she chooses hospice. This is the worst time to stop caring for a patient.
I believe that everyone in the kidney care community should support integrated care for patients with kidney disease. But I do not support the Dialysis PATIENTS Demonstration Act (DPDA). It lacks adequate patient protections, fails to ensure full nephrologist participation, and is limited in scope. Moreover, only the largest providers can participate independently in the DPDA, and building new integrated care networks, as the bill allows, threatens the future viability of a successful, ongoing effort to integrate care, improve outcomes, and control costs: the ESCO Model.
A better way to create networks
My father, Keith Johnson, MD, started Dialysis Clinic, Inc. (DCI) 45 years ago to save the lives of eight patients in Middle Tennessee. Now the largest nonprofit dialysis provider in the country with 230 facilities in 28 states, DCI cares for 15,000 patients on dialysis. We currently operate three ESCOs and have applied to start three more. It is our goal to have 30% of our patients cared for under this innovative model by January 1, 2018.
The Comprehensive ESRD Care Model started with four providers operating in 13 locations. CMS will soon announce even more ESCOs to start next year. In DCI’s ESCOs – in Nashville, TN; Spartanburg, SC; Central New Jersey; and Staten Island, NY – we have seen a transformation of care; we are better able to individualize services for our patients. Based on our initial evaluation, we see a decrease in hospitalization rates and duration.1
We support the ESCO model because it is intentionally designed to allow any provider, large or small, to participate. The ESCO ensures that patients have choice by explicitly stating that every patient “maintains the right to see any Medicare participating health care provider at any time.” And, every ESCO is required to have at least one nephrologist as an owner. But the ESCO model may not be able to survive if the DPDA were enacted as a competing integrated care model.
While I fully endorse and will continue to support the ESCO as the most appropriate means for improving care for dialysis patients, I also believe that there is an opportunity to improve care across the whole spectrum of kidney disease, not just dialysis care. In particular, I believe that integrated kidney care should include patients with chronic kidney disease (GFR ≤ 45) so that we have an opportunity to slow their disease’s progression and decrease the likelihood of needing dialysis. Because transplant is the optimal therapy for many patients with kidney failure, I also believe a comprehensive integrated care model should include patients with a transplant to encourage more access to this valuable treatment option.
For our first 40 years, DCI focused on the best care we could provide to dialysis patients in a clinic. Over the last five years, we have learned how to better care for patients with chronic kidney disease, increase access to transplantation, and expand and improve our care for patients on dialysis. We hope that other providers can have the same transformation. The ESCO is helping us reach these goals, and policymakers can go further to broaden their efforts at comprehensive reform. Unfortunately, the DPDA would be a step in the wrong direction.
- DCI analysis. Results preliminary, subject to change.