A group of five, well-respected biomedical researchers emphasized the importance of providing better care to high-need, high-cost patients in a recent paper published in the New England Journal of Medicine.1 Those diagnosed with end-stage renal disease (ESRD) fit that description precisely, as they require some of the most complex and costly care of any patient population in the United States. Importantly, however, care delivery improvements have been shown to significantly impact quality outcomes, conserve resources, and could serve as models for innovation in in caring for other chronic conditions.
After 20 years of ESRD integrated care demonstrations from The Health Care Financing Administration (HFCA) and Centers for Medicare & Medicaid Services (CMS), two observations have remained constant.
First, patients unequivocally benefit from care coordination; there have been significant improvements in clinical outcomes and patient satisfaction measures since 1996.
Second, and unfortunately, design flaws related to funding, enrollment, or both limited both demonstrations’ viability and national potential for broader deployment.
Because of the clinical benefits, it is clear that the ultimate goal of policymakers should be to ensure that integrated care is available to as many ESRD patients as possible. Yet today’s programs – the Medicare Advantage ESRD Chronic Special Needs Plans (SNPs) and the ESRD Seamless Care Organizations (ESCOs) – serve fewer than 5% of Medicare Fee-for-Service dialysis beneficiaries. In addition, ESRD patients are still prohibited from joining Medicare Advantage plans, although some are enrolled who developed ESRD while being a plan member.
The Dialysis PATIENTS Demonstration Act (H.R. 5942) was introduced in the U.S. House of Representatives on Sept. 7 in order to provide ESRD patients an additional choice for receiving care, and to address the limitations of the other available approaches to care including fee-for-service, MA, SNPs and ESCOs. The bill calls for a time-limited demonstration to evaluate whether newly formed ESRD Integrated Care Organizations (EICOs) can improve care and lower costs. Members of Congress and their staffs drew from multiple rounds of stakeholder input to craft the legislation. The result is a carefully structured integrated care model that incorporates the effective elements of existing programs and addresses their fundamental limitations
The figure below illustrates the major elements of these programs including innovations and limitations. As is apparent, the DPDA retains all of the innovations of the other programs, and eliminates the described barriers and limitations.
The origins of H.R. 5942 lie in the alternative payment models, which CMS has implemented over the last two decades. The legislation adopts elements that have demonstrated their effectiveness in MA, SNPs, ACOs, and ESCOs. With regard to funding, H.R. 5942 is identical to MA and SNPs so that payments are made monthly, allowing participants to cover medical costs and operating expenses. In order to encourage participants to make the required investments and organizational transitions, the legislation utilizes the ESCO’s passive enrollment methodology to ensure enough patients are part of the demonstration. To allow participants to focus fully on coordinating care, H.R. 5942 again mimics the ESCO’s implicit use of the Medicare fee-for-service network and fee schedule to pay providers. Finally, in recognition that ESRD patients have needs that fall outside of Parts A and B, H.R. 5942 allows for participants to offer supplemental benefits, similar to MA and SNPs, and at no added cost to taxpayers.
Overcoming challenges of other models
H.R. 5942 has the benefit of hindsight. All ESRD integrated care demonstrations to date have at least one critical limitation that prevents broader adoption. The legislation not only selects effective elements, it avoids the ineffective ones. While the ESCO has good intent in mandating that nephrologists be owners in the model, the associated capital and risk assumption effectively prohibit small and solo practices from participating. H.R. 5942 instead provides multiple options for nephrologist participation. Ownership is one avenue, but if that is too risky or costly, nephrologists can enter into performance-based arrangements.
Beyond financial arrangements, nephrologists are integral to the success of the integrated care approach as leaders of the interdisciplinary care teams and providers of medical oversight. It should be pointed out that as clearly stated in the legislation, patients continue to retain their own choice of nephrologist and other providers (“…an Organization shall offer at least one ESRD Integrated Care Model that is an open network model…”). In addition, and important to patients, is that patients can opt out of this program each year. This provides a level of patient choice that is not available in the ESCOs where patients do not have the option to opt out.
The other models also do not allow providers to fully address the many needs of ESRD patients. H.R. 5942, however, is designed to allow participants to offer the full range of support by: 1) requiring a robust integrated care strategy, 2) giving the option to provide Part D and Medicaid benefits, and (3) requiring participants to provide transplant transition support]
- Until the ESCOs, integrated care had never been implemented at scale, limiting its potential impact and value.
- When integrated care is at scale, patients and providers start to experience tangible benefits.
- There is no one-size-fits all integrated care program, and the currently available options, ESCOs, SNPs and MA plans, while providing some of the benefits of integrated care all have serious challenges to provider participation and optimization of clinical impact for patients.
- An effective integration program includes a care coordination staff, which closes gaps in care by working with physicians, dialysis clinics, inpatient and outpatient facilities, and many other providers to ensure patients are getting their many needs met.
- As a result, physicians receive disproportionate support for patients who have the highest need, enabling physicians to focus on the more complex, and more fulfilling, problems to solve.
- R. 5942 creates a model that is sensitive to the complex needs of dialysis patients, founded on evidence-based programs, and flexible enough to be viable in any geography which addresses the shortcomings of the other available integrated care vehicles.
- I commend Congress for making kidney health a priority and introducing legislation that along with ESCOs, SNPs and MA plans increases the chances of finding a model that makes integrated care a reality for our patients. These approaches form a strong foundation for CMS and the kidney care community to build upon and inform future iterations of integrated care in the continuing effort to improve the lives of kidney patients.
1. Blumenthal D, Chernof B, Fulmer T, Lumpkin J, Selberg J. Caring for High-Need, High-Cost Patients- An Urgent Priority. N Engl J Med 375:909-11, 2016.