Changing Payment and Care Models for Kidney Patients

After the signing into law of the Affordable Care Act in 2010, the Centers for Medicare & Medicaid Services developed the idea of accountable care organizations (ACOs) as a way to improve health care outcomes while controlling costs. ACOs are legal entities composed of physicians, other providers, clinics, and hospitals, with shared governance toward providing patient care. The idea is to share risk in the management of a given population toward providing high-quality, cost-effective care. It was expected that this approach would foster multidisciplinary preventive care that would improve health and avoid expenses. If organizations save money for Medicare while achieving quality metrics to assure full engagement of patients, they share in the savings. Ultimately, if they spend more, or do not provide quality care, their payments from typical fee-for-service charges are reduced. Thus, they must get a handle on the entire treatment of a patient from primary care to specialist care, including outpatient and inpatient treatment, to have some impact on the quality of care and associated costs.

For patients with chronic kidney disease (CKD), especially those with ESRD, this model brings up many challenges but also opportunities. CKD care is incredibly expensive, complex, and highly specialized. Patients have multiple comorbidities, are frequently hospitalized, and have wide variability in their care. Those already receiving dialysis are cared for under the present rules (at least the vast majority of patients covered by Medicare), with separate quality initiatives and monthly capitation for most of their dialysis-specific costs. Physicians are paid on the number of face-to-face visits per month. The general format of ACOs is that patients are enrolled by primary care groups, which determine the quality interventions and management. Specialists are not central to patient care.

For patients with CKD, it has been suggested that nephrologists have the experience, interaction, and skills to best coordinate the care of these patients, especially those with progressive or advanced disease. These ideas led to Medicare sponsoring the creation of ESRD seamless care organizations. These organizations are intended to capture the overall burden of care and costs for ESRD patients, with shared savings and risks and measures of quality and outcome. This experiment has rolled out slowly, largely embraced by large dialysis organizations and some large health care systems, but the results have not yet been well reported. The results should prove very interesting and should provide a key to whether or not other specialty-specific care models will go forward. Once evaluated, this may determine whether nephrologists and kidney care teams will become the central players in the care of patients with CKD, or rather a captured employed resource for other management organizations.

It strongly behooves us to become intensely involved in these experiments and other launches of ACOs and, in fact, all discussions of models of care of our patients. We must defend the health of kidney patients to the best of our ability while ensuring that the nephrology care team maintains its value and professionalism. The American Society of Nephrology has been closely involved with Medicare and other payers, and I hope all involved parties stay tuned and active in 2016 and beyond.