For now, nephrology groups still on training wheels with value-based care
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In the Center for Medicare and Medicaid Innovation Kidney Care Choices model, nephrology groups do most of the clinical work and take little to no financial risk, placing them at the bottom of the distribution of shared savings.
Though nephrologists may benefit from the Center for Medicare and Medicaid Innovation Kidney Care Choices (CMMI-KCC) model’s new quarterly capitated payment (QCP) for patients with stage 4 and stage 5 chronic kidney disease, reimbursement depends on how often patients are seen; nephrologists still must bill for patient services under the evaluation and management codes.
With renewals due, nephrologists and their specialty accountable care organization enablers (value-based care companies such as Strive Health, Somatus, Evergreen Nephrology, Interwell Health, Monogram Health and others) will have to decide whether to continue with the demonstration in payment year 2024.
Opportunities
What can the renal community learn from the CMMI-KCC models? Some of the primary issues the following:
- Will nephology groups and specialty ACO enablers be successful in reducing the total cost of care during the 5 years of the demonstration?
- Will CMS realize budget neutrality from the demonstration and reach quality improvement goals?
The results of previous CKD and end-stage renal disease demonstrations by CMS, including the ESRD Managed Care (1998-2001), ESRD Disease Management (2006-2010), Care Management for High-Cost CKD Beneficiaries (2006-2011) and the ESRD Seamless Care Organizations (2015-2020), showed improved quality of care and higher beneficiary satisfaction. However, from a budget neutrality perspective, the demonstrations did not save Medicare money.
Enter Alex M. Azar II, the secretary of HHS during the Trump administration. In March 2019, at the National Kidney Foundation Annual Patient Summit, Azar gave a talk focused on the need to slow progression of CKD, increase the use of home dialysis and transplantation, and push forward on innovation.
The result of that discussion was development of the CMMI-KCC models. The focus changed from payers (managed care) and dialysis companies (disease management) to nephrologists. As Azar intended, CKD stage 4 and 5 are included in the KCC model, saying at the NKF meeting that the focus on CKD was “... so we can help Americans escape the burdens of dialysis altogether.”
Financial risk
In August 2019, CMMI asked nephrology groups to participate in the KCC model and take on financial risk. There are models in the CMMI KCC such as the Kidney Care First (KCF) and the Comprehensive Kidney Care Contracting (CKCC) graduated option with lower risks. But if nephrologists want to take part in value-based care, they will need to participate in the CKCC Professional (50% risk for nephrologists/50% risk with CMMI) or the CKCC Global (accept 100% risk) options.
Generally, nephrology groups do not have a lot of reserved capital for investments. To participate in the KCC models, groups needed someone to take the downside financial risk and provide the necessary investments to be successful. The new specialty ACO enablers, backed by private equity, stepped in to provide the funding. For the most part, these companies did not exist prior to 2019.
Nephrologists appreciated the importance of taking the lead but not of the accompanying financial risk.
In 2021, as part of CMMI’s Strategic Refresh, CMS set the goal of having 100% of original Medicare beneficiaries and most Medicaid beneficiaries to be in ACO relationships by 2030.
But there are complications for nephrologists participating in accountable care, including assumption of the downside financial risk; absorbing the operating expenses of improved care management; investing in information systems and analytics to facilitate timely interventions; completing actuarial analysis to track the results; compliance programs; financial guarantees in case of losses and creating nonthreatening relationships with primary care providers.
Specialty ACO enablers have offered assistance, but at what cost and are these the right partners?
Distribution waterfall
When defining shared savings between payer and provider, financial analysts use the term “distribution waterfall.” The calculation prioritizes the distribution of cash flow from savings between the payer (Medicare) and care providers (nephrologists).
If you start at the top of the waterfall with Medicare, the per beneficiary per month (PBPM) savings was $112 to $182 for the first wave dialysis participants in the ESRD Seamless Care Organization and $34 to $52 for the second wave during the course of 5 years.
In addition, CMMI Global CKCC has a 3% benchmark discount on beneficiaries with end-stage kidney disease in payment year 2022 and 2023. That discount increases to 4% in 2024, 5% in 2025, and 6% in 2026, or $273 to $545 PBPM of the ESRD benchmark.
There is also a quality withhold of up to 5% ($0-$254 PBPM) of the total benchmark based on how nephrologists perform on National Quality Forum (NQF) quality measures, including depression (NQF practice guideline #1885), optimal starts (NQF #2594) and a patient activation measure. Based on these PBPMs, it might be difficult to realize savings in treating ESKD. Most of the savings will probably come from treating patients with CKD and attaining the quality measures.
Moving down the waterfall, the next in line are the specialty ACO enablers. These have taken most if not all the downside financial risk and the cost of administrative and care management services. The ACO enablers take a negotiated percentage of the shared savings for administration and a PBPM fee for care management services.
Nephrologist’s share
The remaining savings are divided on a percentage basis among the nephrology participants and their ACO enablers. Aggregation complicates this equation. If a CKCC does not meet the threshold beneficiary numbers, it must aggregate with another CKCC. Aggregation affects the shared savings waterfall at the Medicare level. Fund distribution to each CKCC is based on the ratio of beneficiaries’ months in each CKCC to the total beneficiaries. So, if one CKCC has losses and the other has savings, the CKCC with losses benefits, especially if its beneficiaries’ months are higher. The result could be that nephrologists receive a modest increase from the QCP and a small amount from the shared savings.
Medicare Advantage
Going into payment year 2030, CMS wants to see fee-for-service payments sunset in lieu of Medicare Advantage and Medicare ACOs. With the 21st Century Cures Act opening Medicare Advantage enrollment for beneficiaries with ESKD disease, and the rich supplemental benefits offered, Medicare Advantage plans will dominate in the future.
Alongside these Medicare Advantage plans, original Medicare and its related ACOs will continue to exist to a lesser degree. By 2027, nephrology groups should have the experience and confidence to take on financial risk without ACO enablers and be able to move up the waterfall. Notwithstanding antitrust issues, nephrology practices will continue to consolidate management services. Some practices will integrate with multispecialty clinically integrated networks or with primary care ACOs through contracted, managed or ownership by large payer organizations.
As training wheels are discarded, nephrology groups that participate in value-based care can anticipate a brighter future for their patients and themselves.
- References:
- Comprehensive End-Stage Renal Disease Care (CEC) Model Fifth Annual Evaluation Report. The Lewin Group Inc., 2022. https://innovation.cms.gov/innovation-models/comprehensive-esrd-care.
- End-Stage Renal Disease: Disease Management Demonstration Evaluation Report: Findings from 2006-2008, the First Three Years of a Five-Year Demonstration. Arbor Research Collaborative for Health. https://innovation.cms.gov/medicare-demonstrations/esrd-disease-management-demonstration.
- End-Stage Renal Disease Managed Care Demonstration, Completed Demos & Evaluation Reports. Year 2002. https://innovation.cms.gov/medicare-demonstrations/end-stage-renal-disease-managed-care-demonstration.
- Evaluation of Medicare Care Management for High-Cost Beneficiaries (CMHCB) Demonstration: Village Health’s Key to Better Health (KTBH). RTI International, 2005. https://innovation.cms.gov/medicare-demonstrations/care-management-for-high-cost-beneficiaries-demonstration.
- Innovation Center Home Strategic Direction Refresh, Updated Nov. 7, 2022. https://innovation.cms.gov/strategic-direction-whitepaper.
- Kidney Care Choices (KCC) Model. https://innovation.cms.gov/innovation-models/kidney-care-choices-kcc-model.
- National Kidney Foundation Kidney Patient Summit; March 4, 2019. https://voices.kidney.org/kidney-patient-summit/.
- Nguyen KH, et al. JAMA. 2023;doi:10.1001/jama.2023.1426.
- For more information:
- Gary L. Cellini, PharmD, MBA, is a health care management consultant with expertise in renal disease and alternative payment models. He can be reached at glcellini@gmail.com.
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