The Dialysis PATIENTS Demonstration Act (DPDA) has been the subject of considerable enthusiasm and controversy within the kidney and transplant communities since its introduction in September 2016. The most recent iteration of the legislation, introduced in the U.S. House of Representatives and Senate by a bipartisan group of lawmakers, has garnered substantial support in both chambers, with 185 House cosponsors and 8 Senate cosponsors at press time. Yet the legislation remains a focal point of division within the broader kidney and transplant communities.
At the most basic level, DPDA proposes a Medicare demonstration project that would test a dialysis-focused integrated care model. In the model, dialysis providers and potentially others would assume the full risk of administering all care to dialysis patients enrolled in the model in an open or preferred network setting. By providing integrated care for dialysis patients centered on the dialysis organization, the model seeks to either improve care or generate savings by reducing hospitalizations.
Proponents of the legislation point to the success of integrated care models—such as Accountable Care Organizations (ACO) and ESRD Seamless Care Organizations (ESCO)—in streamlining care and improving outcomes. According to proponents, this legislation would let dialysis centers serve as the primary point of care for dialysis patients, increasing access to comprehensive care for the hundreds of thousands of dialysis patients already receiving care in these settings.
Opponents of the bill have raised concerns about the possibility of increased consolidation in the dialysis market and establishment of perverse incentives that would reduce access to transplantation.
In one provision of the bill, dialysis providers with adequate capitalization can provide plans that resemble Medicare Advantage (MA) for dialysis patients. Some critics maintain that, unlike other MA plans, these plans for dialysis patients would start at dialysis initiation and end at dialysis termination, potentially reinforcing existing silos of care, reducing emphasis on prevention, and providing potential financial disincentives for patients to be referred for transplantation.
Opponents have suggested that only two dialysis organizations would likely be financially capable of assuming the full risk of insuring dialysis patients and claim this would prohibit smaller organizations from participation in the model, further reducing patient choice.
The move toward a value-based comprehensive care system from the current fee-for-service system is in line with broader trends in healthcare, and similar efforts are supported by ASN. However, as outlined in a letter sent by ASN and the American Association of Kidney Patients (AAKP) to the bill’s cosponsors, several provisions of potential concern in the legislation outweigh the potential benefits patients would receive were the bill to be enacted. As described in the letter (see excerpts below), these potential risks include: restriction of patient choice, exacerbation of existing silos of care, exclusion of transplanted patients from the model, and an infringement on the patient-physician relationship and disruption of care.
In a January 31, 2018, statement supporting the legislation, the Renal Physicians Association (RPA) asserted the PATIENTS Act “builds on RPA’s commitment to the use of integrated care models in kidney disease. . . . RPA has supported the ESRD Seamless Care Organization (ESCO) payment model and developed an Incident ESRD Payment Model proposal recently recommended for implementation by the Physician Focused Payment Model Technical Advisory Committee (PTAC).” These integrated care models “offer tremendous potential to improve patient care via reduced hospitalizations, enhanced care coordination, increased availability to social support and nutritional staff, and transportation to care when necessary,” RPA added in its statement.
“With integrated care, patients undergo fewer duplicative and wasteful tests, and they receive holistic care that focuses on the whole patient, not just their disease,” wrote Dialysis Patient Citizens CEO Hrant Jamgochian, JD, on December 3, 2017, in a Real Clear Politics article urging Congress to advance the legislation. “The Dialysis PATIENTS Act seeks to build on the successes of the Comprehensive ESRD Care Model and Medicare Advantage ESRD Chronic Special Needs Plans, while expanding dialysis patients’ access to integrated care,” Jamgochian stated.
DPDA has received significant bipartisan support in the House. Some in Washington, DC, believe the legislation may be included in a package of member-priority health bills after the chamber’s August recess. In the Senate, procedural rules dictate that legislation must receive a score by the Congressional Budget Office (CBO) before being put to a vote on the Senate floor. At press time, CBO had not given the bill a score, likely delaying consideration of the legislation until after the November 2018 election. Every member of the House and one-third of the Senate are up for reelection this fall.
The following are excerpts of a joint letter from AAKP and ASN opposing the legislation that was sent February 28, 2018, to the sponsors of DPDA in the House and Senate. The full text of the letter is available at www.asn-online.org/policy.
“ASN and AAKP appreciate your [cosponsors of the bill] recognition of the significant challenges facing individuals with kidney diseases and kidney failure as well as your commitment to improving their lives. Our organizations were both grateful for the opportunity to provide input on the draft Dialysis PATIENTS Demonstration Act of 2017 (S. 2065), and we commend your efforts to collaborate with our organizations and the rest of the kidney community to refine and further improve the legislation. However, as described below, ASN and AAKP are unable to support the legislation.
“We appreciate the emphasis in the bill on creating a demonstration project to test an integrated care model to increase care coordination. As staunch proponents of the move towards value-based care, we believe that increasing care coordination for patients with kidney diseases—including those with kidney failure—is essential to provide better care for people with these complex needs. ASN and AAKP believe the model proposed in S. 2065 offers elements with the potential for:
Improving patient care via reduced hospitalizations, a serious event from patients’ perspective and one of the costliest aspects of the Medicare ESRD program.
Enhancing care coordination by requiring a range of integrated care strategies.
Increasing access to social workers and dieticians, which current research shows improves long-term patient outcomes.
Improving access to transportation services, a current challenge for many patients that, if resolved, could help improve adherence, outcomes, and quality of life.
“However, ASN and AAKP remain concerned about the possibility of unintended consequences and risks associated with foundational aspects of the PATIENTS Act. These potential risks include:
Restricting patient choice by automatically enrolling patients in the model and not permitting them to move from an ESRD Integrated Care Organization’s preferred network to its open network after a 75-day period. Additionally, patients must wait a full year to make any of the permitted changes, regardless of their care experience.
Exacerbating existing silos of care by excluding patients with earlier kidney diseases and missing critical opportunities to slow or prevent progression to kidney failure as well as improve patients’ lives and avoid more costly care.
Excluding transplanted patients from the model. Not including the optimal therapy for most patients as a treatment option within the model runs contrary to national efforts to encourage more transplantation as a means of improving patient health outcomes and lowering overall costs to taxpayers.
Infringing on the patient-physician relationship and disrupting care by prohibiting nephrologists who are not part of preferred networks from caring for their patients receiving care in units owned by an ESRD Integrated Care Organization participating in the model.
“ASN and AAKP believe that the potential beneficial elements for patients receiving dialysis in the PATIENTS Act could be achieved in more effective ways that minimize or eliminate the potential risks and unintended consequences described above. As such, ASN and AAKP are unable to support S. 2065 at this time.”
