Promote more patient-centered care. Include patients with end stage renal disease as well as later stages of chronic kidney disease. Allow a diversity of dialysis provider sizes and types to participate.
These are among the suggestions for a potential nephrology integrated care delivery model pilot program that ASN—joined by eight other patient and health professional organizations—discussed with leadership from the Centers for Medicare & Medicaid Services (CMS) and the CMS Innovation Center at CMS headquarters in early September (Table 1). Although CMS and the Innovation Center have not formally announced any plans for a nephrology integrated care delivery model pilot program or demonstration project, ASN and the other participants commended them for their interest in examining strategies to improve care and reduce costs for patients with kidney disease and voiced strong support for such a program.
In addition to thanking CMS administrator Jonathan Blum, Innovation Center Acting Director Richard Gilfillan, MD, and their staffs for their consideration of a pilot project focused on patients with kidney disease, ASN and the other groups provided recommendations for key considerations the agency should take into account to ensure the success of a pilot project and yield the most meaningful improvements for patients.
Although CMS and the Innovation Center are still considering the project, at this time, it is generally anticipated that a pilot program would likely entail a dialysis provider assuming responsibility for the care of a set number of patients with kidney disease, developing innovative ways of delivering and improving care for them, and having the opportunity to share in savings or receive a bonus payment from CMS for meeting certain quality metrics.
One theme that ASN and the other participating patient and health professional groups emphasized was the importance of considering including late-stage CKD patients—as well as patients with ESRD—in a pilot program. Improving care coordination and enhancing access at that stage could provide significant patient benefit, through means such as establishing appropriate vascular access, selecting the optimal modality, and arranging for nutritional supplements. It could also help defray costs, such as by reducing the number of patients who “crash” into dialysis in the emergency room, or have increased morbidity and mortality due to catheter infections.
Among the challenges to including this population are how to define “late stage CKD,” and whether it is possible to involve patients with CKD who are not yet Medicare beneficiaries. Yet CMS and the Innovation Center possess a unique opportunity to profoundly transform care for patients with kidney disease, and ASN hopes the agency will engage with the nephrology community to develop creative solutions.
Other suggestions that participants in the meeting encouraged Mr. Blum, Dr. Gilfillan, and their staffs to consider included:
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Prospectively specifying the evaluation methodology that will be used to define success or failure.
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Improving patient access to transplantation, including pre-emptive transplantation.
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Including a role for patient peer mentoring.
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Incentivizing timely placement of appropriate vascular accesses.
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Allowing provider organizations that are large and small, and for-profit and non-profit, to participate.
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Utilizing the patients’ time during in center dialysis treatments to coordinate care for other comorbidities, such as heart disease or diabetes, and to provide educational interventions.
“Overall, I think that ASN and the other patient and health professional groups thought it was a constructive, interactive meeting, and sincerely appreciated CMS and the Innovation Center’s consideration of the ideas our groups presented,” said L. Lee Hamm, ASN Accountable Care Organization Task Force Chair, who represented ASN at the meeting. “Accounting for the perspectives and experiences of these two key constituencies in the design of a pilot program will be important for CMS and the Innovation Center to ensure its success. We all look forward to continuing the dialogue with them to capitalize on this exciting opportunity to improve care for our patients.”
