Risk Arrangement Considerations for Nephrologists

Accountable provider organizations of all types (e.g., clinically integrated networks [CINs], independent practice associations [IPAs], multi-specialty groups [MSGs] and accountable care organizations [ACOs])* are increasingly used as partnership and network agreements. These types of agreements can create better alignment among market stakeholders through a shared focus on achieving quality and efficiency of care and reducing total medical spend. They may be precursors to additional risk-taking by accountable provider organizations that plan to extend to full capitation.

While no organizations that take risk are absolutely alike, and no risk-taking agreements are completely similar, there are common themes to CIN and ACO agreements negotiated by IPAs, MSGs and integrated delivery systems that you may want to be aware of when evaluating such proposals. In some cases, a CIN or IPA that also has a Medicare ACO may ask you to sign an agreement that links you to the CIN or IPA as well as an ACO participation agreement. In all instances, it makes sense to consult legal counsel for your practice and your practice’s financial advisor to help decipher the terms and obligations of these contracts. Some of the items to consider before you sign any type of participation agreement are noted below.

Important considerations

• There may be limitations to how well the organizations and non-nephrologist physician partners understand the care required for kidney patients and the parameters of exceptional clinical performance specific to kidney care.
• The parent organization for the accountable care entity may be able to contract with commercial insurers on your behalf. This could alter your ability to contract with the same payer on behalf of your practice.
• The agreement may provide limited or no shared savings opportunity for specialties (including nephrology)
• There may be a strong emphasis within the accountable care entity to focus on a narrow network of providers, which could exclude the providers and services that you normally access for your patients.
• There may be additional information technology or interoperability requirements in which your practice would need to invest.
• You may be able to obtain access to additional data on your patients that can help drive improved outcomes.
• If you are already working with providers within the accountable care entity, you may be able to achieve additional alignment with them.
• Some, but not all, accountable care entities can satisfy the MACRA requirement as an advanced alternative payment model (APM).

Patients with kidney disease and the professionals who care for them occupy a unique niche in our healthcare spectrum. This niche, in some ways, is more advanced than other aspects of U.S. healthcare when one considers the impact of

• having the Centers for Medicare & Medicaid Services (CMS) directly involved in reimbursement and measurement of performance in end stage renal disease for so many years
• the legacy of outpatient care in dialysis facilities with evidence-focused medicine (exemplified by the early adoption of clinical practice guidelines in the nephrology community)
• the availability of national-level data via the United States Renal Data Systems and the Scientific Registry of Transplant Recipients, and
• the coexistence of capitated payments with fee-for-service.

In this regard, nephrologists should remember they are some of the original and most-practiced providers of not just great patient care, but population health. It is important that they maintain awareness of what is happening in their market when determining whether an accountable care arrangement would offer the best position for their practice and their patients.

* Glossary

Clinically Integrated Network (CIN): An organization that may include providers, facilities and
hospitals in a defined geography, to establish a provider network intended to improve quality of care, efficiency of care, and reduce the total cost of care for patients cared for by the organization.  This organization may work to link up the entities that participate in some way through interoperability, and may take and manage risk.

Independent Practice Association (IPA): An association of independent practices formed for the purpose of consolidating shared services (e.g., group purchasing and payor contracting)

Multi-Specialty Group (MSG): Doctors from various clinical specialties who work together within a single group practice, usually under the same tax identification number.

Management Service Organization (MSO): An organization owned by a group of physicians, a physician hospital organization or third-party entities that provide practice management and administrative support services to providers.

Medicare Accountable Care Organizations (ACOs): A variety of CMS-sponsored alternative payment models through which physicians, hospitals and other providers come together to provide coordinated, high-quality care, improve outcomes and reduce costs. Examples include the Medicare Shared Savings Program (MSSP), NextGen ACOs and ESRD Seamless Care Organizations (ESCOs).