CMMI Models, Part I: Overview and What This Could Mean for Providers

Part of the process of aligning providers around holistic care for patients with CKD or ESRD has been the movement away from fee for service (FFS) reimbursement toward value-based payments. Where fee-for-service payments promote fragmentation, value-based payments have the economic advantage of being able to unify and consolidate priorities among various health care providers.

The goals of the five new payment models proposed by the Center for Medicare & Medicaid Innovation (CMMI) appear to be a step in the right direction for physicians, patients and society; however, it is unclear whether the design of the models will help achieve these goals. These models reportedly represent the amalgamation of input from physicians through nephrology associations, as well as from patient groups and industry experts.

The mandatory ESRD Treatment Choices (ETC) model includes two payment changes, each designed to increase the rates of home dialysis and transplantation. The first payment in this model, known as the Home Dialysis Payment Adjustment (HDPA), provides a bonus of up to 3% to physicians and dialysis providers for the treatment of patients choosing home dialysis. This payment bonus declines over time and ceases in 2023. The second payment is the Performance Payment Adjustment (PPA), which will provide either a bonus or penalty to physicians and dialysis centers based on home dialysis and renal transplant rates. The PPA, whose bonus and penalty grow over time, is a points-based system with a normal distribution pattern—meaning some physicians and dialysis centers will benefit financially, while others will be penalized. In this model, the upside benefit is equivalent percentagewise for physicians and dialysis providers. The downside risk, however, is larger for dialysis providers.

Within the PPA, two-thirds of the overall score will be based on home dialysis rates and one-third will depend upon transplantation rates. This skewing of payment is appropriately related to the greater ability to impact home dialysis options compared to transplantation. Additionally, physicians and dialysis centers can earn points within the PPA either based upon their percentile rank within their hospital referral region (HRR) or upon year-over-year improvement.

Under the ETC model approximately 50% of Centers for Medicare & Medicaid (CMS) beneficiaries (and accordingly their nephrologists and dialysis centers) will be selected to participate and ultimately be compared against non-participants. CMS does plan to monitor Standardized Mortality Ratio (SMR) and Standardized Hospitalization Ratio (SHR), along with home dialysis and transplantation rates to evaluate the success of the model.

Contrary to the ETC model, full details of the voluntary Kidney Care First (KCF) and the Comprehensive Kidney Care Contracting (CKCC) models have not yet been published; more information on these models is expected from CMS in November 2019. These models are reportedly designed to enhance advanced CKD care, slow the loss of kidney function, delay initiation and improve transition to dialysis, and increase access to kidney transplants.

The KCF model is a physician-only model with bonuses or penalties assigned to physician practices based upon home dialysis and renal transplant penetration as well as yet-to-be-determined clinical outcomes.  The CKCC models are designed around “contracting entities” that will likely include nephrology practice(s), a transplant program and a dialysis provider.  The entities will assume varying amounts of responsibility for cost savings as well as certain quality outcomes, including home dialysis and renal transplant rates.  Attribution in these models will be at the patient level, though details remain scarce.

With various levels of upside benefit and downside risk, CMS should recognize that this massive change requires investment and establish models that will reward and allow for investment in the early years. Similarly, like the current Comprehensive ESRD Care (CEC ESCO) models, the ability to formally collaborate as a single contracting entity has the potential to foster greater collaboration between physician practices, dialysis organizations and other providers around comprehensive, integrated chronic care management.  Participation in these models will depend on the full program design details to be released with the formal Request for Application (RFA).

Three of the four voluntary models qualify as Advanced Alternative Payment Models (AAPM) allowing physicians to be potentially eligible for a 5% bonus on all Medicare FFS payments. These bonus payments, along with appropriate Anti-Kickback Statute (AKS) waivers to promote greater collaboration and reduce waste, would be great advancements as physician practices begin to transform care away from the classic physician-patient relationship towards a multi-disciplinary, team-based approach.

Optimistically, pending the details of these models, physician practices will be in a position to begin changing how they deliver advanced renal care. With the nephrologist serving as the “captain of the ship,” patients will be able to receive holistic care from a broad group of specialists, potentially including non-physician practitioners, a nurse navigator, renal dietician and social worker. Ideally, this approach to care delivery will facilitate individualized care, patient/family member education and shared decision making—each of which are likely to improve clinical outcomes while reducing cost.

Finally, it is worth noting that these new payment strategies comprise a grand experiment. If successful at improving care, reducing costs or both, this is likely to be the beginning of greater value-based reimbursement changes, not the end. It appears as though this new emphasis on alignment between providers could lead to meaningful transformation in care delivery, both upstream in CKD and downstream in ESRD.

Related information on the CMMI models from Dr. Giullian was published in Nephrology News & Issues.
Upcoming post: CMMI Models, Part II: Increasing Home Dialysis