- CMS is expected to begin testing payment and care delivery models for its Comprehensive End-Stage Renal Disease Care initiative (CEC) in January of 2015, but the program continues to draw criticism from providers. The initiative is intended to promote care coordination to curb costs and improve care for patients in end-stage renal failure, who account for 6% of all Medicare spending ($34 billion in 2011).
- The agency is introducing end-stage renal disease seamless care organizations (ESCOs) for the 500,000 beneficiaries suffering from kidney disease. ESCOs operate similar to the agency's ACO model.
- Many providers are concerned that CMS is not targeting patients in earlier stages of the disease to improve care quality. The agency has also not provided clear guidelines as to how quality targets are going to be set and assessed.
According to Robert Sepucha, the vice president of corporate affairs at dialysis provider Fresenius Medical Care, "The economics are not great, the quality targets are not known and they haven't told us what interventions are going to be dictated by the waivers."
Sepucha also said that he worries that the guidelines of the program will be so strict that they will hamper new intervention efforts. For example, providing low-income patients free transportation to the clinic is prohibited under traditional Medicare reimbursement. If the program won't permit that kind of approach, Sepucha says that Fresenius will have to go "back to the drawing board."
Fresenius, one of the dominant providers of dialysis in the country, has submitted about six applications to be included in the program.
Other providers are also expressing concerns that the quality metrics guidelines are being produced internally at CMS, rather than with sufficient input from the provider community.
"The problem is very few of the quality measures have been field-tested, and some are tested in the general population but not the dialysis population," Dr. Edward Jones said. Jones is the chairman of Kidney Care Partners, a coalition of patient advocates, dialysis professionals, care providers and manufacturers.
CMS, despite receiving what is likely a low number of applications, has not expressed concern, stating that the Pioneer ACO payment model and the Comprehensive Primary Care Initiative were able to begin providing care before quality metrics were completely established. A preliminary list of metrics has been released; the document includes measurements for quality of life, mortality rates, care coordination (e.g., readmission and hospitalization ratios) and disease management (i.e., extremity amputation). The agency plans to release a final list, which it says will show "substantial overlap" with the preliminary list, in the late fall.
While the deadline for application for large dialysis providers has lapsed, small providers have until September 15 to file for participation.