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President Trump executive order, new payment models target kidney care

CMS said it would encourage development of wearable or implantable artificial kidneys through cooperation between developers and the FDA.

Susan Morse, Managing Editor

Following an executive order from President Trump on Wednesday, the Centers for Medicare and Medicaid Services has proposed five new payment models for providers treating patients with chronic kidney disease.

One is a required payment model and there are four optional models, all designed to encourage home dialysis and kidney transplants.

The proposed required end-stage renal disease treatment choices model would adjust certain Medicare payments to facilities and managing clinicians selected for participation, through upward or downward payment based on their home and transplant rates.

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To avoid penalizing ESRD providers with sicker patients, the treatment choices model would risk adjust the home dialysis and transplant rates used for purposes of the performance payment adjustments.

Beneficiaries would maintain freedom of choice among healthcare providers, and would not see a change in their Medicare cost-sharing. The payment adjustments would begin January 1, 2020, and end on June 30, 2026. 


The four optional initiatives include the kidney care first and the comprehensive kidney care contracting models that will test new payment options aimed at delaying the need for dialysis and encouraging kidney transplantation. 

In the kidney care first model, participating nephrology practices will receive adjusted fixed payments on a per-patient basis for managing the care of patients with late-stage chronic kidney disease and patients with ESRD.

The payments will be adjusted based on health outcomes and utilization compared to the participating practice's own experience and national standards, as well as performance on quality measures.

In addition, participating practices will receive a bonus payment for every patient aligned to them that receives a kidney transplant based on the transplant remaining healthy for up to three years after the surgery. 

The comprehensive kidney care contracting models include the graduated, professional and global models. The capitated payments will be similar to the capitated payments under the kidney care first model, but the kidney contracting entities – which consist of nephrologists, transplant providers, and other healthcare providers including dialysis facilities – will take responsibility for the total cost and quality of care for their patients, and in exchange, can receive a portion of the Medicare savings they achieve.

The optional models are expected to run from January 1, 2020, through December 31, 2023, with the option for one or two additional performance years, at CMS's discretion.


The models are aimed at improving health and reducing the cost of care.

They were announced in conjunction with President Trump today releasing the Advancing American Kidney Health Executive Order to deliver on three goals: fewer patients developing kidney failure, fewer receiving dialysis in dialysis centers and more kidneys available for transplant.

The President's Executive Order also calls for HHS to launch a public awareness campaign to increase knowledge of chronic kidney disease, which 40 percent of American patients do not know they have; reform the organ procurement and management system in the United States to significantly increase the supply of transplantable kidneys; expand support for living donors through compensation for costs such as lost wages and child care expenses; encourage the development of wearable or implantable artificial kidneys, through cooperation between developers and the Food and Drug Administration; and support for KidneyX, a public-private partnership between HHS and the American Society of Nephrology.

The models come out of the CMS Center for Medicare and Medicaid Innovation.


The current Medicare payment system encourages in-center hemodialysis as the default treatment for patients beginning dialysis.

A beneficiary who chooses home dialysis has a greater flexibility to adjust the hours and frequency of their treatment, CMS said. It is the most common type of dialysis and was used by about 88 percent of dialysis patients in 2016, according to the Government Accountability Office.

There are more than 430,000 Medicare fee-for-service beneficiaries with ESRD who spend an average of 12 hours a week receiving in-center hemodialysis. Many beneficiaries with ESRD suffer from poorer health outcomes, such as higher hospitalization and mortality rates, which are often the result of underlying disease complications and multiple comorbidities.

Approximately 20% of dollars in traditional Medicare--$114 billion a year--are spent on Americans with kidney disease. Yet of the more than 100,000 American who begin dialysis to treat end-stage renal disease each year, one in five will die within a year.

The Department of Health and Human Services wants to: reduce the number of Americans developing end-stage renal disease by 25 percent by 2030; have 80 percent of new ESRD patients in 2025 either receiving dialysis at home or receiving a transplant; and double the number of kidneys available for transplant by 2030.


"President Trump is tackling the toughest issues in American healthcare, and few areas need reform more than the way we treat kidney disease," said HHS Secretary Alex Azar. "Decades of paying for sickness and procedures in kidney care, rather than paying for health and outcomes, has produced less-than-satisfactory outcomes at tremendous cost. Through new payment models and many other actions under this initiative, the Trump Administration will transform this situation and deliver Americans better kidney health, more kidney treatment options, and more transplants."

Twitter: @SusanJMorse
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