Significant Update from CMS on Voluntary Models and ESCOs, Including Q&A

By David White

June 4, 2020

The Kidney Care Choices (KCC) Model, also known as the “voluntary model”, is moving forward beginning April 1, 2021 – a delay from the original start date of January 1, 2021 – due to the Public Health Emergency (PHE). The Centers for Medicare & Medicaid Services (CMS) Innovation Center announced that in addition to delaying the start of the model, the agency will also provide a second window for applications in 2021 for new participants with a starting date for that group of January 1, 2022. Additionally, applicants approved for the April 1, 2021 start date will have the option to delay their start date to January 1, 2022 without penalty or having to reapply. Also covered in this announcement was an extension of the Comprehensive ESRD Care Model (CEC) until March 31, 2021, with financial adjustments for performance year 2020 due to COVID-19. The CEC created the ESRD Seamless Care Organizations (ESCOs) of which there are 33 nationally.

Some Q&As for readers are:

1. When will KCC participants be notified?

Answer: CMS has not announced the exact date but has indicated it will be by mid-June.
 

2. How will CMS deal with the impact of COVID-19 and health care costs in 2020 for both ESCOs and CEC?

Answer: There are two answers here.

First, for KCC participants in the voluntary model, there will changes in quality benchmarks to reflect changes in the period of the performance year in 2021. The details of the adjustments for dealing with 2020 as a benchmark will be provided in communications between CMS and those accepted into the program, and ASN will provide those details when they become available.

Second, for ESCOs, CMS plans to do the following:

  • Reduce the 2020 downside risk by reducing shared losses by the proportion of months during the PHE;
  • Cap ESCOs’ gross savings upside potential at 5% gross savings;
  • Remove COVID-19 inpatient episodes;
  • Remove the 2020 financial guarantee requirement;
  • Continue to monitor the impact on 2020 quality reporting.


3. What does this mean for the mandatory model?

Answer: The voluntary model, KCC, and the mandatory model, the ESRD Treatment Choices (ETC) Model, are complementary payment models just for kidney care resulting from the Advancing American Kidney Health (AAKH) initiative. While there was no announcement regarding the ETC mandatory model, the model is expected to be announced in its final version by the end of the summer of 2020. ASN made numerous recommendations to modify and improve the ETC as originally proposed.

More details on the KCC for readers are that it includes four options for participation – the Kidney Care First (KCF) Option (nephrologists only) and three Comprehensive Kidney Care Contracting (CKCC) Options – the graduated, professional, and global CKCC Opinions. The KCC focuses on slowing the progression of kidney disease before a person reaches kidney failure and incentivizes more kidney transplantation, while also prioritizing

  • Later and better starts on dialysis for Medicare patients with kidney disease;
  • Better coordination of care for these individuals with kidney disease and kidney failure to reduce total cost of care;
  • More individuals receiving kidney transplants and staying off dialysis for longer;
  • Different financial risk options for nephrologists and other providers and suppliers to take on financial accountability.


- And includes the following patients:

  • Medicare beneficiaries with CKD stages 4 and 5;
  • Medicare beneficiaries with ESRD receiving maintenance dialysis; or
  • Medicare beneficiaries who were aligned to a KCF practice or kidney contracting entities (KCE) by virtue of having CKD stage 4 or 5 or ESRD and then later received a kidney transplant.
     

For the Kidney Care First (KCF) Option, nephrologists and nephrology practices will receive adjusted capitated payments for managing Medicare beneficiaries with CKD stages 4 and 5 and ESRD, and they will be eligible for upward or downward payment adjustments based on the quality of their performance and improvements in their performance over time. The KCF Option will include Benefit Enhancements to enable nephrologists to strengthen care coordination for beneficiaries with CKD stages 4 and 5, as well as new financial mechanisms to enable participants to manage cash flow.

For the CKCC Options, nephrologists and nephrology practices must partner with transplant providers, and may partner with dialysis facilities and other providers and suppliers to become Kidney Contracting Entities (KCEs). KCE nephrologists will receive adjusted capitated payments for managing Medicare beneficiaries with CKD stages 4 and 5 and kidney failure. The payments will be adjusted based on health outcomes and utilization of resources compared to the participating practice’s own experience and national standards, as well as performance on quality measures – exactly how this will be achieved in the wake of the PHE are the details participants should receive soon.

In addition, participating practices will receive a bonus payment for every patient aligned to them that receives a kidney transplant based on the transplant remaining healthy for up to three years.

Transplant bonus:

  • $2,500 for year one
  • $5,000 for year two
  • $7,500 for year three


ASN will continue advocating for nephrologists and patients as these models progress and Medicare makes adjustments for all of its kidney programs in light of the impact of the PHE.

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Author:
David White
Body:

The Kidney Care Choices (KCC) Model, also known as the “voluntary model”, is moving forward beginning April 1, 2021 – a delay from the original start date of January 1, 2021 – due to the Public Health Emergency (PHE). The Centers for Medicare & Medicaid Services (CMS) Innovation Center announced that in addition to delaying the start of the model, the agency will also provide a second window for applications in 2021 for new participants with a starting date for that group of January 1, 2022. Additionally, applicants approved for the April 1, 2021 start date will have the option to delay their start date to January 1, 2022 without penalty or having to reapply. Also covered in this announcement was an extension of the Comprehensive ESRD Care Model (CEC) until March 31, 2021, with financial adjustments for performance year 2020 due to COVID-19. The CEC created the ESRD Seamless Care Organizations (ESCOs) of which there are 33 nationally.

Some Q&As for readers are:

1. When will KCC participants be notified?

Answer: CMS has not announced the exact date but has indicated it will be by mid-June.
 

2. How will CMS deal with the impact of COVID-19 and health care costs in 2020 for both ESCOs and CEC?

Answer: There are two answers here.

First, for KCC participants in the voluntary model, there will changes in quality benchmarks to reflect changes in the period of the performance year in 2021. The details of the adjustments for dealing with 2020 as a benchmark will be provided in communications between CMS and those accepted into the program, and ASN will provide those details when they become available.

Second, for ESCOs, CMS plans to do the following:

  • Reduce the 2020 downside risk by reducing shared losses by the proportion of months during the PHE;
  • Cap ESCOs’ gross savings upside potential at 5% gross savings;
  • Remove COVID-19 inpatient episodes;
  • Remove the 2020 financial guarantee requirement;
  • Continue to monitor the impact on 2020 quality reporting.


3. What does this mean for the mandatory model?

Answer: The voluntary model, KCC, and the mandatory model, the ESRD Treatment Choices (ETC) Model, are complementary payment models just for kidney care resulting from the Advancing American Kidney Health (AAKH) initiative. While there was no announcement regarding the ETC mandatory model, the model is expected to be announced in its final version by the end of the summer of 2020. ASN made numerous recommendations to modify and improve the ETC as originally proposed.

More details on the KCC for readers are that it includes four options for participation – the Kidney Care First (KCF) Option (nephrologists only) and three Comprehensive Kidney Care Contracting (CKCC) Options – the graduated, professional, and global CKCC Opinions. The KCC focuses on slowing the progression of kidney disease before a person reaches kidney failure and incentivizes more kidney transplantation, while also prioritizing

  • Later and better starts on dialysis for Medicare patients with kidney disease;
  • Better coordination of care for these individuals with kidney disease and kidney failure to reduce total cost of care;
  • More individuals receiving kidney transplants and staying off dialysis for longer;
  • Different financial risk options for nephrologists and other providers and suppliers to take on financial accountability.


- And includes the following patients:

  • Medicare beneficiaries with CKD stages 4 and 5;
  • Medicare beneficiaries with ESRD receiving maintenance dialysis; or
  • Medicare beneficiaries who were aligned to a KCF practice or kidney contracting entities (KCE) by virtue of having CKD stage 4 or 5 or ESRD and then later received a kidney transplant.
     

For the Kidney Care First (KCF) Option, nephrologists and nephrology practices will receive adjusted capitated payments for managing Medicare beneficiaries with CKD stages 4 and 5 and ESRD, and they will be eligible for upward or downward payment adjustments based on the quality of their performance and improvements in their performance over time. The KCF Option will include Benefit Enhancements to enable nephrologists to strengthen care coordination for beneficiaries with CKD stages 4 and 5, as well as new financial mechanisms to enable participants to manage cash flow.

For the CKCC Options, nephrologists and nephrology practices must partner with transplant providers, and may partner with dialysis facilities and other providers and suppliers to become Kidney Contracting Entities (KCEs). KCE nephrologists will receive adjusted capitated payments for managing Medicare beneficiaries with CKD stages 4 and 5 and kidney failure. The payments will be adjusted based on health outcomes and utilization of resources compared to the participating practice’s own experience and national standards, as well as performance on quality measures – exactly how this will be achieved in the wake of the PHE are the details participants should receive soon.

In addition, participating practices will receive a bonus payment for every patient aligned to them that receives a kidney transplant based on the transplant remaining healthy for up to three years.

Transplant bonus:

  • $2,500 for year one
  • $5,000 for year two
  • $7,500 for year three


ASN will continue advocating for nephrologists and patients as these models progress and Medicare makes adjustments for all of its kidney programs in light of the impact of the PHE.

Date:
Thursday, June 4, 2020