On July 10, 2019, the Centers for Medicare & Medicaid Services released a proposed rule that outlines two new proposed mandatory models: the Radiation Oncology Model (RO Model) and the End-Stage Renal Disease (ESRD) Treatment Choices Model (ETC Model). The proposed rule includes details about the payment, participation, and timeline of each model. Comments on the proposed rule are due on September 16, 2019.

For information on the RO Model, please see our coverage here.  

In conjunction with the ETC Model proposal, CMS also announced additional voluntary payment models related to kidney care: the Kidney Care First (KCF) Model and the Comprehensive Kidney Care Contracting (CKCC) Models. These models were announced by the CMS Innovation Center and will not go through the federal rule-making process.

CMS Proposes Mandatory ETC Model

The ETC Model is a mandatory model focused on greater use of home dialysis and kidney transplants to preserve or improve care for Medicare beneficiaries while reducing spending. The model would include two payment adjustments: the Home Dialysis Payment Adjustment (HDPA) and the Performance Payment Adjustment (PPA). Proposed payment adjustments would be implemented over a six-and-a-half-year window running from January 1, 2020 to June 30, 2026.

The Home Dialysis Payment Adjustment (HDPA) is a positive adjustment on certain home dialysis and related claims during the initial three-year period of the model. CMS proposed to adjust payments for home dialysis claims with dates from January 1, 2020 through December 31, 2022 through the HDPA. There will be two types of HDPAs: the Clinician HDPA and the Facility HDPA. The Clinician HDPA is the payment adjustment to the Monthly Capitation Payment (MCP) for managing ESRD beneficiaries for a managing clinician. The Facility HDPA is the payment adjustment to the adjusted ESRD PPS per Treatment Base Rate for a participating facility for a home dialysis claim. CMS is proposing the following payment adjustment schedule for the HDPA:

 

	CY 2020	CY 2021	CY 2022
Magnitude of Payment Adjustment	+3%	+2%	+1%

 

The Performance Payment Adjustment (PPA) is a positive or negative adjustment on dialysis and dialysis-related Medicare payments for both home and in-center dialysis based on rates of kidney and kidney-pancreas transplants and home dialysis among attributed beneficiaries. The PPA would begin July 1, 2021 and run through the end of the model on June 30, 2026. As the magnitude of the PPA increases over the calendar years of the ETC Model, the magnitude of the HDPA would decrease.

Participants in the ETC model will include all Medicare-certified ESRD facilities and all Medicare-enrolled Managing Clinicians in selected geographic areas. CMS is proposing to randomly select Hospital Referral Regions (HRRs) for inclusion in the model. Managing Clinicians will include clinicians who bill the Monthly Capitation Payment for managing ESRD beneficiaries. The rule also proposes excluding ESRD facilities that have fewer than 11 attributed beneficiary years during a given measurement year for the application of the PPA.

CMS is proposing to use two quality measures for the ETC model:

• Standardized Mortality Ratio (SMR)- NQF #0369; and
• Standardized Hospitalization Ratio (SHR)- NQF #1463.

These measures are used for Dialysis Facility Reports and the ESRD Quality Incentive Program (ESRD QIP) so CMS notes that no additional reporting will be required of ETC participants. CMS is not proposing to tie these two measures to payment under the ETC model.

The proposed rule notes that CMS also considered an alternative start date of April 1, 2020. If the Model began then, all intervals would remain the same length but would start and end 3 months later. CMS is seeking comments on this alternative time line.

CMS believes that the ETC model is compatible with other dialysis-focused CMS programs and models, but the agency notes it will work to resolve any potential overlaps that could result in repetitive services or duplicative payment of services. ETC participants will have to notice beneficiaries of their participation in the ETC model. Medicare beneficiaries enrolled in a Medicare Advantage plan will not be included in this model. In addition, patients receiving dialysis for an acute kidney injury (AKI) only will also be excluded.

Additional Voluntary, Kidney-Focused Models Announced

CMS, through the Center for Medicare and Medicaid Innovation (CMMI or the Innovation Center), announced additional models, the Kidney Care First (KCF) Model and the Comprehensive Care Contracting (CKCC) Models. Within CKCC are the Graduated, Professional, and Global Models. These models are intended the delay the progression of chronic kidney disease (CKD) to end-stage renal disease (ESRD), thus delaying the need for dialysis. CMMI intends to emphasize education and prevention within each of the models.

The KCF Model and the CKCC Graduated, Professional, and Global Models are not mandatory. They are intended to start on January 1, 2020 and end December 31, 2023. Should the models be successful, the agency will consider up to two additional years of the models. Nephrology practices and nephrologists will be eligible to participate with applications opening in fall 2019.

Beneficiaries eligible for attribution to practices that participate in the models will include beneficiaries with CKD in states 4 and 5 and beneficiaries with ESRD receiving maintenance dialysis. While full details on payment in the models has not yet been released, CMS provided a high-level overview of how participating providers will be reimbursed.

KCF Model Includes Adjusted Capitated Payments

Participants in the KCF model will receive adjusted capitated payments for care managements of aligned beneficiaries. Payments will be adjusted based on health outcomes, utilization, and quality measures. No details on which quality measures have been released. KCF practices will also receive a bonus payment for attributed beneficiaries that receive a kidney transplant; this will be paid over the three years following the transplant, provided the transplant remains successful.

CKCC Model Participants May Take on Risk

CKCC participants will also received adjusted payments for care management of aligned beneficiaries, but will also have different accountability frameworks as outlined below:

• CKCC Graduated Model: certain participants will begin under a lower-reward, one-sided risk model with greater risk and potential reward being incrementally phased in.
• CKCC Professional Model: participants can earn 50% of shared savings or be liable for 50% of shared losses based on total cost of care for Medicare Part A and Part B services.
• CKCC Global Model: this model will see risk adoption for 100% of the total cost of care for all Parts A and B services for attributed beneficiaries.