CMMI Models, Part III: Increasing Transplants

The recently launched Advancing American Kidney Health (AAKH) initiative aims to increase awareness of chronic kidney disease (CKD) and prevent the growth of end stage kidney disease (ESKD) by reducing the number of patients who develop ESKD and better treating those with this irreversible disease. The third in our series (following “CMMI Models, Part II: Increasing Home Dialysis”), this post provides tactics to help achieve the two objectives key to increasing transplants among ESKD patients and the associated financial incentives and disincentives.

Why transplantation?

While ESKD patients have three treatment options: dialysis, transplantation, and conservative care, the majority (70%) today are on dialysis. Dialysis is not the ideal treatment option for most patients. It can be difficult to achieve the desired quality of life and even well-managed dialysis can be life-consuming for patients (and care partners). Moreover,  the total cost of care is approximately $90,000 per year for each Medicare patient.

Kidney transplantation, on the other hand, offers patients a treatment that restores kidney function as closely as possible to their own kidneys and helps patients achieve a higher quality of life than dialysis. While costs in the post-transplant year can be similar to average annual medical costs for a Medicare ESKD patient, medical costs fall thereafter to approximately $35,000 per year. Given that average kidney transplant survival is 10 to 12 years, patients who receive kidney transplants also tend to live longer. Despite these positives, there is a problem underlying kidney transplantation: a shortage of donor kidneys. This shortage has created a waiting list of nearly 100,000 Americans with an average wait period of three to seven years.

Addressing organ demand

The AAKH aims to improve organ availability, and double the number of kidneys available by 2030, by achieving two objectives:

1. Increase deceased organ recovery and reduce organ discards. The estimated annual kidney discard rate lies near 20% representing 3,500 kidneys procured from deceased donors but not transplanted. It is hypothesized that many of these kidneys could be utilized with education and implementation of appropriate protocols (e.g., expedited procurement processes, accelerated placement of certain kidneys), and treatments (e.g., treating recipients of organs infected with hepatitis C with medications) and heightened performance monitoring.
2. Increase living donation. In order to increase the living donation rate (which accounts for 30% of U.S. transplants), the initiative aims to remove financial barriers that may deter would-be donors. For example, the Health Resources and Service Administration (HRSA) plans to revise the income threshold for the Reimbursement of Travel and Subsistence Expenses Toward Living Organ Donation program and expand the list of eligible expenses to include coverage for lost wages and family expenses.

Financial incentives for nephrologists and providers

The AAKH initiative also includes payment reform that attempts to align incentives with increasing transplant numbers. The Center for Medicare & Medicaid Innovation (CMMI) models in the AAKH initiative (mandatory and voluntary) intend to boost the number of transplants performed through financial incentives and disincentives for nephrologists and dialysis providers. In the ESRD Treatment Choice or mandatory model, Nephrologists and Dialysis providers who meet or exceed the risk-adjusted transplant rate will alter their 72X coding and monthly capitated payment (MCP) for all their dialysis patients. However, those who fall below the rate will see sizeable cuts (potentially greater than 10%) in 72X billing and MCP by 2025. In the voluntary models, nephrologists and/or the kidney contracting entities whose patients undergo transplantation and remain “successful” for a minimum of three years (off dialysis) will receive bonus payments over the three year timeframe of $15,000 per patient.

By increasing kidney transplantation, the AAKH initiative hopes to improve the health and quality of life for Americans facing ESKD while cutting the total cost of health care. Along with the aforementioned tactics, other strategies and innovations (such as the development of an artificial kidney) are also associated with transforming the treatment of ESKD and supporting a transition to value-based health care.

An editorial by Dr. Becker on the AAKH initiative and CMMI models was published in Modern Healthcare.