In 1971, Shep Glazer was dialyzed before Congress’s Ways and Means committee, and shortly thereafter, Congress allowed anyone with End-Stage Renal Disease (ESRD) to be covered by Medicare. In 2021, The 21st Century Cures Act allowed anyone with ESRD to join a Medicare Advantage plan. These provisions have saved many Americans from bankruptcy but have also lead the federal government to spend nearly 1% of its overall federal budget on ESRD.
In the traditional fee-for-service system, companies like DaVita and Fresenius have capitalized on this legislation, often partnering with Nephrologists to present in-center dialysis as the only option for patients. Despite the cost to the government and time burden to patients, a recent study showed that older patients with kidney failure who started dialysis right away lived for an average of 770 days — just 77 days longer than those who never started it.
“No one ever mentioned anything about options. The few times I saw a nephrologist each time… you know, they sent me to their [in-center] dialysis clinic.” – Patient Advisory Group Participant
The less expensive and more liberating options of in-home dialysis and only medication management must also be presented to patients, and CMMI’s Kidney models have done so, while increasing home dialysis and optimal starts rates.¹ First, with the Comprehensive ESRD Care (CEC) Model (2015 - 2020) and then with Kidney Care Choice (KCC), which is set to expire at the end of 2026. While immediate cost savings from these models have been limited, they establish a foundation for future success by improving care pathways, aligning incentives, and prioritizing prevention.
As our healthcare system transitions to value, Kidney care is an important specialty of focus due to its high cost nature and the nephrologists role as the patient’s “quarterback.” Continuing the Kidney program while incorporating key learns from past models will bend the cost curve while delivering higher quality care to patients. While CMMI has already incorporated some of these key lessons (see file in footnotes), the next iteration of the model should include the following changes.
MSSP’s benchmarking mechanisms have been refined for over a decade and provide a more stable platform for participants to transition into value. Various elements of the MSSP program would benefit the Kidney program, such as a prior savings adjustments, regional FFS adjustments, and upfront payments.
For example, prior savings adjustments increase ACOs’ benchmarks based on the savings generated in the prior three years, mitigating the ‘ratchet effect’. Likewise, the regional FFS adjustment typically increases the benchmark for high performing ACOs, creating more opportunity for savings. In this adjustment, if ACOs have done a better job at controlling costs than the region, the regional costs will be weighted more heavily in the benchmark and increase it. Additionally, the new pre-paid shared savings mechanisms in MSSP provide ACOs with much-needed cash flow through a straightforward payment method. Similar pre-paid shared savings elements were recently added to CKCC.
In MSSP’s prepaid shared savings methodology, ACOs receive a portion of their projected savings in advance (aka pre-paid shared savings), rather than having to negotiate downstream FFS reductions with preferred providers (like in ACO REACH). In MSSP, ACOs must currently spend at least 50% of these payments on direct beneficiary services otherwise not payable in Traditional Medicare; however, this restriction should not be levied on Kidney ACOs (or any for that matter), as it prevents ACOs from appropriately engaging with downstream specialists. These pre-paid shared savings differ from the Advance Investment Payments (AIP) in MSSP, where the intent is to provide necessary capital to launch new ACOs / establish infrastructure. These payments should also be offered to new Kidney ACOs with inexperience managing risk. Lastly, CMS should allow voluntary alignment for participants in the Kidney care program, as it is in MSSP.
These changes can be made by folding the Kidney model into MSSP or creating an entirely new kidney model. In this merging, Kidney ACOs would be able to choose from the full array of tracks offered in MSSP. Additionally, this program would need to include various specifications to make the model kidney specific.² Leveraging MSSP as the ‘chassis for innovation’ will create a more trusted brand for congressmen and ACOs alike, thereby signaling long-term security to ACOs / investors and enabling the transition to value (see full argument here).
The previous iteration of the optimal starts measure was calculated by using the 2728 form. In this updated measure, optimal starts should be calculated using claims data, so that a patient who dialyzes with one lumen of the CVC used and one needle placed in AVF or AVG will count as an optimal start.
Suppressed claims hinder financial analysis across multiple program components (e.g., stop-loss analysis, claims proxy for home dialysis true-up). When a beneficiary opts out of data sharing, CMS should anonymize personal health information (PHI) and assign a “dummy” identifier, enabling participants to track claim types and total patient costs. Additionally, for patients still aligned to a KCE despite provider termination, claims should not be suppressed, as this severely limits the KCE’s ability to manage care effectively.
To ensure comprehensive and accurate documentation of beneficiary complexities, CMMI should implement the following changes for CKCC: