Aiming to Coordinate Care, ACO Proposed Rule Falls Short


In January 2012, the Centers for Medicare and Medicaid Services (CMS) will launch a new congressionally mandated initiative designed to help improve the quality of patient care.

In the initiative currently proposed, accountable care organizations (ACOs) may not be well positioned to appropriately care for patients on dialysis or who have a recent kidney transplant. Despite this concern, the ASN ACO task force believes that ACOs may offer significant benefits to the chronic kidney disease patient population; however, significant modifications to the existing proposal would be necessary.

ACOs are envisioned by Congress as a new, coordinated approach to care delivery and reimbursement that will drive down costs while ensuring quality. While ACOs were mandated by the Affordable Care Act (ACA) of 2010, CMS must issue regulations that specify how ACOs will function. In March, CMS issued an ACO Proposed Rule outlining its vision for the program and solicited public comment. The ASN ACO Task Force, chaired by Lee Hamm, MD, conducted a comprehensive review of the 427-page proposed rule and drafted a comment letter to CMS detailing ASN’s recommendations and concerns. According to Hamm, “Overall, while the Task Force recognized the potential ACOs hold for advancing care and driving down costs, we were very concerned that the proposal, as written, could do more harm than good for patients on dialysis or with a recent kidney transplant.” (See Q and A on p. 2).

According to the ACA, an ACO is a network of providers, hospitals, and other health care organizations that agree to assume responsibility for providing care to a specific group of at least 5000 Medicare beneficiaries. If an ACO meets certain quality standards for patient care and reduces the cost of that care to below what CMS expects it would otherwise have cost, the ACO will get to keep some of the savings. This sets the ACO model apart from the traditional fee-for-service payment system, in which providers are not held to any quality benchmarks and generally receive greater reimbursement for administering more tests and procedures.

Aside from this basic framework, Congress gave CMS significant discretion in determining the specifics of which provider types can participate in ACOs, how ACOs are structured, and the quality standards ACOs must meet. The proposed rule constitutes CMS’ first effort at tackling the details.

For the nephrology community, perhaps the most important detail in the proposal was CMS’ crystal-clear statement that it envisions ACOs as organizations centered exclusively on primary care. The only providers who may have patients assigned to them to form an ACO are primary care providers (internal medicine, general medicine, family practice, and geriatric medicine) who provide a predefined set of primary care services. Although nephrologists and renal care providers may provide services to patients who are assigned to ACOs, CMS proposes that no specialists may form an ACO. Discussion of a potential option for a “renal-specific” ACO had been suggested by some in the kidney community, but CMS has strongly indicated that specialty-specific ACOs are not on the table at this time.

In the proposed rule, CMS recommended a number of approaches to improve the quality and reduce the cost of patient care, including promoting evidence-based medicine best practices, patient engagement and surveying, reporting on cost and quality measures, coordination of care, and individualized care plans. While these approaches are all valuable steps to improving the quality of care, many of these key ACO care processes are already routinely undertaken in dialysis units in an ESRD-specific format and setting, as implemented by the Medicare ESRD Program. It is unclear how dialysis care would fit into an ACO model.

ASN articulated concern that aligning the complex existing dialysis care system with a primary care–oriented ACO that uses quality metrics designed for the general population would be an extraordinarily complex task for dialysis units, the ACO, and nephrologists without adding value to individual kidney patients’ care. Subjecting dialysis patients to multiple sets of rules and processes—of both the ACO and the dialysis unit—could have an unintended negative influence on quality of care, leading to dual processes, conflicting care mandates, duplication of resources, and fragmented patient care.

CMS laid out 65 proposed quality metrics that ACOs must achieve to be eligible for shared savings. While potentially of great value to the general patient population receiving care in an ACO, many of the proposed quality metrics may not be appropriate for kidney patients. Yet CMS did not indicate that the quality measures might apply differently to dialysis or transplant patients. Nor did CMS provide any detail regarding case-mix adjustment of the quality measures to account for variation in patient populations. ASN commented that these omissions are problematic, and could create perverse incentives for an ACO to provide care appropriate only for the general population in order to meet the standards necessary to be eligible for shared savings—to the detriment of complex patients with kidney disease. According to Amy Williams, a member of the task force, “patients on dialysis simply have different care needs from the general patient population, and it was unclear based on CMS’ proposal that it would differentiate between the two groups. It is imminently possible that ACOs could be penalized for providing appropriate care to a patient on dialysis if that care led to an outcome divergent from the standards set for the general population.”

CMS proposes to assign beneficiaries to an ACO based on the primary care provider (PCP) from whom they receive a plurality (exact percent unspecified) of their primary care services (Table 1). ASN emphasized to CMS that many nephrologists serve as PCPs for their kidney patients, particularly those in late-stage CKD, those maintained on dialysis, and those who have received a recent transplant. To preserve this vital patient-nephrologist relationship, and to prevent any unintended consequences for specialized patients in a primary care ACO, ASN recommended that dialysis patients and recent transplant recipients—populations who often receive the plurality of their care from a nephrologist—should not be attributed to an ACO.


This arrangement would permit patients with earlier stages of kidney disease to remain in the ACO and benefit from the coordinated care processes it facilitates, but, as indicated by their disease progression, eventually allow them to receive the specialized care they need—be it dialysis or transplantation—without affecting the ACO’s overall performance on the quality metrics.

Because care of patients with CKD, especially those with more advanced CKD, is extremely complex and requires close, multidisciplinary collaboration between the patient’s PCP and nephrologist as well as with other physician and nonphysician providers in order to limit complications of the disease, including progression to kidney failure, ASN commented that ACOs may offer significant benefits for CKD patients, with some key modifications.

Processes that an ACO would facilitate—such as electronic patient data collection and sharing, quality monitoring, and individualized care plans, may lead to better outcomes and more patient-centered care for CKD patients. However, these outcomes will be dependent on whether the care processes and quality standards ACOs select are appropriate for CKD patients’ unique health status. ASN strongly supports efforts to improve outcomes for CKD patients within the context of ACOs. For instance, vascular access planning could be streamlined in an ACO model through improved and timely communication between PCPs and specialists, as well as through incentives for vascular access to be placed prior to the start of dialysis, when appropriate. ASN suggested that CMS establish timely creation of a dialysis access as a quality measure for patients with late stage CKD, creating an incentive for ACOs to establish a dialysis access in their patients.

ASN was one among many hundreds of organizations and individuals to submit comments to CMS regarding the ACO Proposed Rule. Many commentators—including those who were among the ACO program’s strongest proponents prior to release of the proposed rule—expressed concerns. The 65 quality measures have been widely panned as overly “burdensome” and “prescriptive,” and commentators have also expressed concern that ACOs will not know which patients it is responsible for until years after care has been provided (under CMS’ proposal patients will be retroactively assigned to ACOs). Overall, CMS’ highly anticipated proposal has been largely criticized by hospitals and physicians as too onerous with too little potential financial gain to justify the risks of participation.

Over the coming weeks, CMS will review the feedback and is anticipated to alter its proposal. CMS will likely then issue either a final rule (which would not be open for comment) or an interim final rule (upon which CMS could solicit comment). ASN and the ACO Task Force will continue to follow CMS’ ACO activities closely leading up to implementation of the program, and stand ready to help CMS further assess the effects of ACOs on the kidney patient population or to offer any additional guidance.

To read ASN’s comments to CMS on the ACO proposed rule, please visit the ASN Public Policy web page.

Having provided feedback to CMS on the proposed ACO rule, the ASN ACO Task Force will remain in place to address other aspects of new accountable care models. The task force is investigating the possibility of a potential CMS demonstration project on integrated care models for the CKD and ESRD populations. The task force will also continue to follow and respond to CMS’ next steps related to the proposed ACO rule.