If at first you do not succeed, try, try again.

That seems like a fitting mantra for the Centers for Medicare & Medicaid Services and the End-Stage Renal Disease Program. Dialysis care has always been under the microscope and is the program that regulators like to tinker with; it’s a small specialty with beneficiaries pri.marily funded by one payer and can thus be subjected to regulatory experimentation.

The unfortunate thing is with all this white noise and plenty of “let’s try this,” CMS is losing sight of what should be the goal: working with providers to improve quality. The cost of the ESRD Program represents 6.3% of the Medicare budget; more than that, it encompasses 500,000 people whose lives are dependent on dialysis. Let’s focus on improving their future with models of care that work. Have we lost sight of that?

The long and winding road

Policy making for the ESRD Program has had many bumps along the way. There were multiple payment policies for Epogen in the early 1990s and changes to the monthly capitated payment. Of course, some poli.cies stick around way beyond their natural life, like the dreaded sustainable growth rate that dictates Medicare physician pay; the fee-for-service based composite rate for dialysis treatments, and the worn-out Conditions for Coverage that lasted over two decades. Sometimes you have to force CMS’ hand and bring in your Congressional friends to stop the runaway train, like what happened with implementation of CrownWEB. It took a lot of arm twisting for CMS to see the light and realize that patience and pilot studies made more sense before a program-wide implementation.

Crash and burn: ACO model, five-star rating

The ongoing resculpting of the Comprehensive ESRD Care model is another example of poor planning. Initially, it wasn’t attractive to small providers (the ones that CMS really needed to warm up to if integrated care becomes universal); included too much risk and not enough reward; and left little time—and opportunity for input from the renal community—to develop quality measures.

If you were a nephrologist and partner in a practice, you were considered a bad seed.

So the Innovative Center threw a party and nobody showed. That forced the agency to rebuild the model into something more appealing. There are still alot of unanswered questions (see our coverage of the ACO application process in National News starting on page 10), and even with a year delay and more time granted to submit applications, another “Hail Mary” approach may be heading our way.

Which is unfortunate. CMS should realize that the renal community is preparing for the future and sees real value in a integrated care model—as long as the plan makes economic sense. And, the CKD element needs to be included—somehow. A continuum of care between the early and late stages of kidney disease through kidney failure needs to be funded (read our cover story from the September issue online about the “Healthy Transitions” program at the North Shore-Long Island Jewish Health System) and CMS needs to figure out a way to do it.

Five-Star and dialysis: beyond movies and hotels

Which leads us to the shaky Five-Star Rating system for dialysis clinics. Like Dialysis Facility Compare, which is the basis for the rating system, the intentions are good: Medicare beneficiaries want to know who provides the best care and as a regulator, CMS wants to share that information. But the system still needs to be fleshed out; the one CMS developed for nursing homes has flaws, according to a recent review by the New York Times. Let’s learn from that review, and develop a better 5-star sys.tem: one with agreed-upon quality measures that dialysis providers can control, one that patients feel is helpful and accurate. They aren’t spending a night at a hotel and commenting about the quality of the coffee or rudeness of the front desk clerk; they are selecting a health care provider that will perform a complex medical procedure. Make sure the information is on target and focused on the important measures of quality.

For me, how about: “Who has the best five-star rating on cannulators?” That’s where I’m going:)