It seems like the renal community is going through an endless tunnel of change. It’s not clear if regulators and Congress decided to define this particular decade as one of change for publicly funded health care, but it certainly has been like one of those bucking bull rides you might see in a Texas country bar. And it’s not clear when the ride will end.

Some of the upheaval has come from initiatives like:

  • The bundled payment system for dialysis care, the first big change in over three decades.
  • The Quality Incentive Program, which tries to tie performance with payment.
  • CROWNWeb, off and running on its shaky legs in June 2012, it will become a bigger and bigger part of dialysis clinic operations.
  • greater release of information to the public, such as a more robust database for Dialysis Facility Compare and the most recent release of Medicare-paid physician salaries (read a well thought out blog on this topic entitled  “2012 Medicare billing data: Should we care how much you billed?” by author Terry Ketchersid, MD, at
  • Physician practices will face off with CMS over adaption of new ICD-10 codes for services, starting next October.
  • Debate continues over how to banish the sustainable growth rate formula used by CMS to determine Medicare physician pay
  • The Accountable Care Act will no doubt have an impact on Medicare dialysis patients.

All of that since 2000 – and the decade still has five years to go.

The payment source

Much of that flurry of activity is dictated by what is essentially a single-payer system for kidney care. Medicare pays billions each year direct to nephrologists and dialysis providers and transplant centers and their staff for the treatment of over a half a million patients with chronic disease. It’s an expensive endeavor, and the payer wants to know whether it is getting a good deal for the money spent.

One way to control that is to develop new models of payment that also offer some new approaches to improving quality. Treatment outcomes with kidney disease is a core measure of the therapy’s success.  Dialysis or transplant – or the potential for a new wave of wearable kidneys –– need to deliver a workable treatment that delivers good quality care.

We have been hearing for many years that the Medicare dollar doesn’t stretch far enough to make it in the treatment environment. You’re sunk if you have a clinic with Medicare-only patients (Medicaid pay is even worse). Medicare’s payment and regulatory arm, the Centers for Medicare and Medicaid Services, knows that (while they still pushed through a 12% cut to the bundle last summer, they did try and limit the pain). There has to be a better way to move the centerpiece from financial reward to rewarding for quality.

The potential for ‘accountable care’

The tunnel of change has taken us more recently to the Comprehensive ESRD Care Initiative, or renal Accountable Care Organization model. After several false starts, CMS has put its best foot forward on this demonstration. The rules in the new RFA (request for application) have been re-directed to give this demonstration a fighting chance. CMS bowed to many of the demands because, logically, it wants all sizes of providers to participate. That’s no easy task; larger providers have a number of advantages over smaller organizations based on their patient numbers, greater access to working capital (participation in this demo will be expensive for any provider), and access to expertise.

It’s clear that CMS wants to see the Comprehensive ESRD initiative to work. ACOs are part of its bloodline now; it has over 35 ACO demos going on in other medical fields. Let’s see if it fits for the kidney patient.




Where do we go next?

It’s always important to know what your audience thinks of your work and the direction it takes––they are your judge and jury. Last month we asked many of you to complete a short survey about what NN&I is doing well and where we can improve. The response was excellent with close to 1,000 surveys returned. We were happy to hear that our coverage of the important issues in renal care was on target, but we also got some valuable suggestions on other important topics. I’ll delve into those in upcoming “First Word” columns. We want to thank everyone who took the time to share their views.