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Care Quality

"Doing Well By Doing Good" Advancing American Kidney Health Initiative.

 

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Christopher: Hello. I'm Christopher Springmann, and Doing Well by Doing Good is a recurring theme for this month's NephTalk guest, Dr. Graham Abra, MD, as he discusses the Executive Order on Advancing American Kidney Health, especially the key roles played by nephrologists. These include, for example, the Kidney Care First, or KCF, Model. Dr. Abra: The first of the voluntary models is known as the Kidney Care First Model. This one is a model that is for nephrologists only. And what it does is it changes the way that payments are provided for patients with CKD IV, V, those who are on dialysis, and those after kidney transplant.

The Kidney Care First Model is only available for patients with Medicare insurance. It does not apply to patients with commercial insurance or other types of insurance. Instead of billing for individual services, the model provides for quarterly and monthly capitated billing. The monthly capitated billing that's provided for dialysis payments is set equivalent to the current two- to three-visit payment code for both home patients and in-center patients regardless of the number of times that the patient is seen throughout the month. This allows nephrologists to do well by doing good. Christopher: Please, stay tuned for the entire seven-minute program featuring Dr. Abra and more information on the Executive Order.

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Dr. Abra: Dear nephrology colleagues, thank you for joining me today. My name is Dr. Graham Abra, and I'm a clinical nephrologist at Stanford University. I am the medical director at WellBound San Jose and also the senior director of medical clinical affairs at Satellite Health Care.

Today we're going to be going over an overview of the Executive Order. We'll then be talking about the voluntary and mandatory payment models that are part of the Advancing American Kidney Health Initiative. And finally, we'll be closing with important points for nephrologists to be aware of as we go into the early part of 2020.

There is really no more exciting time to be a nephrologist than the current moment. We are seeing unprecedented changes beginning to happen in the kidney-care world. And this is a really amazing thing for our patients and the kind of care that we can provide them. I think as many of you are probably aware, we are now entering the era of the Advancing American Kidney Health Initiative, and this initiative is one that aligns really nicely with the things that we all feel are important as nephrologists for the care of our patients.

The Executive Order brings some ambitious goals to the kidney-care community. It asks us to reduce the number of Americans developing end-stage kidney disease by 25% by 2030. It sets a target of having 80% of new patients start their care with either dialysis at home or with a preemptive kidney transplant. And it asks the entire community to try and double the number of kidneys available for transplant by the year 2030.

Now, these are ambitious goals, and whether or not we can achieve them is unknown. But certainly, we can all agree with them as nephrologists that they are things that are important for our patients. In addition to the clinical targets that are laid out by the Executive Order, it also instructs the Health and Human Services Department to develop a public awareness campaign. It's already been announced that the American Society of Nephrology and the National Kidney Foundation are going to be leading this charge, bringing more awareness to the public about the importance of kidney disease and the care that we provide for patients with kidney issues.

The Executive Order also is going to be supporting the development of an artificial kidney, a goal that has long been one of the kidney community. We are hopeful that in coming years we see progress on this important therapy for patients.

So the Advancing American Kidney Health Initiative also brings to us two categories of payment model, one, a mandatory model which will be randomly assigned to 50% of what are known as "hospital referral regions," the other a type of voluntary model of which there are two different types-- the Comprehensive Kidney Care Contracting Model and the Kidney Care First Model.

The mandatory payment model is known as the End Stage Renal Disease Treatment Choices Model, or ETC as it's sometimes abbreviated. This model is going to be randomly assigned to 50% of hospital referral regions across the United States. These hospital referral regions are defined in the Dartmouth Atlas, and they do not necessarily conform to state lines or zip codes. They are instead drawn around hospital referral regions.

This model will impact payment to both nephrologists and to dialysis providers. The basics of the model are that based on a nephrologist and a dialysis provider's rate of home therapies and rate of transplantations, payments will either be increased or decreased to both nephrologists and dialysis organizations.

In addition to the payment modifications that will be made by the mandatory model, it also expands the provision of what is known as "kidney disease education" to patients. Kidney disease educations is a Medicare benefit that can be provided to patients currently by nephrologists and advanced practitioners. In the modification, this kidney disease education will be able to be provided to patients by non-nephrologists and nonadvanced-care practitioners. And types of patients that will be able to receive this patients is expanded to those with CKD IV, V, and those on dialysis for up to the first six months of their treatment.

The first of the voluntary models is known as the Kidney Care First Model. This one is a model that is for nephrologists only. And what it does is it changes the way that payments are provided for patients with CKD IV, V, those who are on dialysis, and those after kidney transplant. The Kidney Care First Model is only available for patients with Medicare insurance. It does not apply to patients with commercial insurance or other types of insurance.

Instead of billing for individual services, the model provides for quarterly and monthly capitated billing. The monthly capitated billing that's provided for dialysis payments is set equivalent to the current two- to three-visit payment code for both home patients and in-center patients regardless of the number of times that the patient is seen throughout the month.

In addition to the monthly and quarterly capitated payments, the model also provides bonus payments or penalty payments based on the achievement of certain quality metrics. This allows nephrologists to do well by doing good.

Similar to the Kidney Care First Initiative, there is also the Comprehensive Kidney Care Contracting Model. This model must contain nephrologists and transplant providers but can also include other organizations, such as dialysis providers. This Comprehensive Kidney Care Contracting Model has many of the same payments adjustments as the Kidney Care First Model but expands the participants to include transplant centers and, potentially, dialysis providers.

So here are some important things to know. First, by April 1, 2020, you are going to know whether or not you're included within the mandatory payment model, also known as the End Stage Renal Disease Treatment Choices Model. If you are included in this model, it is going to change how you are paid for your kidney care services for dialysis patients. If you're within the mandatory models, your reimbursement will be based on your percentage of patients on home dialysis and your percentage of patients that receive a kidney transplant. For nephrologists who are not included in the mandatory model, nothing changes. However, in the future, it may be that models like the mandatory model may be expanded to all nephrologists, and we need to be cognizant of this as a kidney care community.

And in terms of the voluntary models, for those that apply, they are going to be providing us with new learnings about how to best take care of patients with kidney disease in a more comprehensive, coordinated way.

There's never been a more important time than now for physicians and nephrologists to take leadership roles in not only these payment models and how we take good care of patients in the more comprehensive, coordinated models but also in the public awareness campaigns, the development of new technologies, and our approach to how we take the best care of kidney patients. This is really a call to arms for all nephrologists to take a leadership position and to make sure that we take the best possible care of our patients.

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