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A view from the transplant center
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At first glance, it is hard to say how the Advancing American Kidney Health initiative payment models will affect the operations or the finances of kidney transplant centers. While increasing the total number of kidney transplants performed is heavily incented in both the mandatory ESRD Treatment Choices and voluntary payment models, the financial carrots and sticks in this regard are directed only at general nephrologists and dialysis providers.
In the mandatory and voluntary payment models, achieving or exceeding a risk-adjusted “transplant rate” will significantly alter the Monthly Capitated Payment for all of a nephrologist’s dialysis-dependent patients, as well as the 72X coding for dialysis providers. Falling below the “transplant rate” results in significant cuts to both nephrologists and dialysis providers, with the downside risk for the lowest performers exceeding -10% of MCP and 72X billing by 2025.
While this existential threat will focus the minds of nephrologists and dialysis providers, how will they meaningfully move the transplant rate needle or at least prevent it from deflecting in the wrong direction? Nephrologists and dialysis providers can work to increase rates of referral and apply pressure on transplant centers to efficiently move patients through the transplant evaluation process, but it is not clear that increased rates of referral or wait listing will reliably translate into more transplants. Transplant centers will probably feel some pressure from nephrologists to reduce their organ discard rate, but this will have to be tempered by the ongoing regulatory burden on transplant centers to achieve high patient and graft survival benchmarks. Historically, these quality benchmarks have promoted risk aversion in organ and candidate acceptance behaviors.
While CMS has hinted at a de-escalation in their regulatory focus, details have been conspicuously absent. Perhaps the most important opportunity for collaboration in the new payment model is unlocking new and efficient ways to identify potential living donor candidates, which is probably the only way to realistically grow the total number of transplanted kidneys.
It is not clear whether kidney transplant centers have an appetite for taking on financial risk for total costs of care. Indeed, it remains unclear in the ESRD Treatment Choices even whether enlisting a transplant “center” is mandatory for creating a “Kidney Contracting Entity (KCE),” an entity required to participate in a risk-bearing Comprehensive Kidney Care Contracting (CKCC) payment model. While the KCE must include a transplant “provider” in partnership with a general nephrology practice, it is not clear whether a transplant “provider” must be a transplant center or simply a designated transplant surgeon and/or a transplant nephrologist.
While partnering with a general nephrology practice in one of the risk-bearing CKCC models would provide the opportunity for transplant provider partners (however defined) to qualify for an advanced alternative payment model (APM) designation, and by extension exemption from merit-based incentive payment system under the Medicare Access and CHIP Reauthorization Act of 2015, it is difficult to say the extent to which transplant providers will be attracted to that perk. To qualify for an APM, transplant providers would have to partner with nephrology practices to take upside and downside risk on the total cost of care for patients with advanced chronic kidney disease as well as patients on dialysis, not just transplanted patients. Given the millions of dollars at risk, it would seem imprudent for a transplant provider to take on risk for a patient population without additional and better resourced partners, like a large dialysis provider or a large hospital system, which could also bear most of the upside and downside financial risk. Also, participating transplant providers must formally declare their participation in a KCE by Jan. 1, 2020, a short runway to make a confident decision about taking on substantial financial risk.
In any event, apart from the Advancing American Kidney Health payment models, kidney transplant centers are facing a litany of current and near-future challenges, including:
A shift in allocation policy to promote geographic equity in access to organs, which will generally entail shipping kidneys from low- to high-population density areas with concomitant increases in organ acquisition costs, cold ischemia time and (probably) delayed graft function, as well as significant swings in organ transplant volume for many centers; and
Beginning in 2021, the opportunity for Medicare patients with ESRD to enroll in Medicare Advantage plans administered by private payers. As these patients are not counted as “Medicare” patients for the purpose of reporting organ acquisition costs, a large shift of patients to privately administered Medicare Advantage plans means kidney transplant centers will be able to report and collect less money on their Medicare Cost Report, which is a key source of revenue.
All told, already faced with plenty of risk, kidney transplant centers should be wary of taking on more.
- For more information:
- Benjamin E. Hippen, MD, FASN, FAST, is a clinical professor with the department of medicine at the University of North Carolina at Chapel Hill School of Medicine in North Carolina and with Metrolina Nephrology Associates, P.A. in Charlotte, North Carolina. He is also a Nephrology News & Issues Editorial Advisory Board Member.
Disclosure: Hippen reports he is compensated for consulting work for Fresenius Medical Care, North America. Opinions are his own and do not represent the opinions of Fresenius Medical Care, North America, nor Atrium Health, nor Metrolina Nephrology Associates, P.A.
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