Kidney health care has been constrained for decades by silos of care: chronic kidney disease (CKD), kidney failure and dialysis, and kidney transplant. ASN and its members have long advocated for a change in payment policy and care delivery approaches to disrupt a system that traditionally placed most all the financial incentives on kidney failure treatment. “The current Medicare End-Stage Renal Disease benefit program has long focused on dialysis at the expense of going upstream to slow CKD progression and focusing on pre-emptive transplantation,” said Susan E. Quaggin, MD, FASN, ASN President.
That was until now. The Kidney Care Choices (KCC) model, often referred to as the voluntary model, is designed to upend those dynamics. A Centers for Medicare & Medicaid Services (CMS) statement proclaimed, “KCC is designed to help health care providers reduce the cost and improve the quality of care for patients with late-stage chronic kidney disease and ESRD [end-stage renal disease]. This model also aims to delay the need for dialysis and encourage kidney transplantation.”
The KCC model had an open-application period in late 2019 and early 2020, resulting in reportedly hundreds of applications (the exact number was not publicly disclosed) to participate in the model, which is created and overseen by the Center for Medicare and Medicaid Innovation (CMMI, created by Congress in 2010 through passage of the Affordable Care Act [ACA]). The performance period was originally set to begin January 1, 2021. COVID-19 changed the timeline of the program twice now. In 2020, the period was pushed back to April 1, 2021, and now that date has been moved to January 1, 2022.
“While we were disappointed by the delay, this process has been building for over 10 years now, and we have to move toward the goals involved: more upstream kidney health care and more transplant,” Quaggin said. “Also, we have made it clear to CMMI that the top priority following this change must be to make sure nephrologists who were planning to be in an AAPM (Advanced Alternative Payment Model) and not reporting in MIPS (Merit-based Incentive Payment System) are taken care of and not placed in financial jeopardy or given an unexpected reporting burden. For now, CMMI says they will be able to file a hardship exemption for reporting in MIPS for 2021.”
Since the beginning of 2021—as the start date of April 1, 2021, approached—many ASN members who had planned on being KCC participants began expressing serious concerns about new requirements being incorporated into the voluntary model. ASN, therefore, requested that CMMI review several issues of concern to members. With the extension of the implementation period through the end of 2021, ASN intends to push CMMI to address the following issues raised by members:
-
Withholding 30% of payments to prevent clawbacks for CMS overpayment. Participants are concerned that the withhold will severely affect cash flow for all practices, particularly small ones, and in many cases preclude participation.
-
Removing the dialysis facility fee in the model has raised concern that the move will negatively impact the ability of some groups to participate in the model, thereby limiting the scope of kidney patient participation, which is key to the model’s success.
-
Compensating with a transplant bonus is an excellent incentive to increase transplantation and may help make up for these two cash flow issues in the longer term. However, because it is paid over 3 years, it cannot overcome the immediate cash flow challenges that these two issues create in the short term.
-
Overcoming challenges of administering the patient activation measure (PAM) and where the input of that data will occur.
-
Discussing the payment levels of the CKD quarterly capitated payment (QCP).
ASN sees the KCC models as vitally important steps to improving kidney care but strongly advocates for the above issues to be addressed before late fall 2021. Any program adjustments aside, COVID-19 delays remain a concern for CMMI, patients, and practices.
“COVID-related delays have become common and annoying, I agree,” Quaggin commented, “but we are pursuing big changes for patients, and we have to keep our eyes on the prize.”
