Renal Care Model Results Called ‘Promising But Modest’

An analysis of the recently concluded Comprehensive End-Stage Renal Disease Care (CEC) alternative payment model found promising but modest results over the four performance years, with improvements on some quality and health care utilization measures as well as a decrease in total payments.

The CEC Model is an Advanced Alternative Payment Model (Advanced APM) that creates financial incentives for dialysis facilities, nephrologists, and other Medicare providers to coordinate care for Medicare beneficiaries with ESRD. The model is designed to improve clinical and patient-centered outcomes for Medicare beneficiaries with ESRD, while promoting value and reducing per-capita payments.

The analysis, conducted by the Lewin Group for the Centers for Medicare & Medicaid Services, noted that the magnitudes of these improvements were generally larger in in the first two years of the program. “The CEC Model resulted in a $151 million aggregate reduction in payments for CEC beneficiaries over the first four performance years,” the report noted. “This reduction was primarily generated through a reduction in hospitalizations and readmissions. The number of hospitalizations and the percent of beneficiaries with at least one readmission each decreased 3 percent across the four performance years. Additionally, ESCOs [ESRD Seamless Care Organizations] reported various interventions to improve adherence to dialysis. These interventions resulted in an increase in the number of dialysis sessions and a decrease in payments and hospitalizations for ESRD-related complications.”

The report added that the CEC Model appears promising, with lower payments, improvements in some utilization measures, and no obvious indicators of unintended or adverse consequences. Part A and B Medicare per-beneficiary per-month payments declined by $80. Relative to the average payments in the pre-CEC period ($6,394), this represents a decrease in payments of 1 percent. The payment reductions were most evident in Medicare Part A with significant reductions in acute inpatient hospitalizations and readmissions. The number of dialysis treatments increased, which could be a consequence of fewer missed treatments or scheduling an extra dialysis treatment.

Hospitalizations and payments for dialysis-related complications declined. Significant reductions in catheter use were also observed, suggesting overall improvements in the quality of dialysis care, along with improvements in preventive services. Utilization and payment results reinforce the qualitative findings from ESCO site visits. Improving coordination of care across settings was cited as a key objective by the ESCOs, backed by new investments in areas such as care coordination staff and IT to facilitate enhanced communication across providers.

Reducing hospitalizations and readmissions was a particular area of emphasis. Similarly, the observed increase in the number of dialysis treatments may reflect a decrease in skipped outpatient treatments, either directly or indirectly (due to less time in hospital), which was another key emphasis cited by the ESCOs and supported by quantitative analyses showing an increase in the likelihood of receiving dialysis as scheduled and having missed treatments re-scheduled under the CEC Model relative to the comparison group.

An analysis of mortality showed that the CEC was associated with better survival. Although the magnitude of the effect was modest, it appeared to be stronger for beneficiaries aligned earlier in their course of dialysis, the report said.

The ESCOs were created in two separate waves. The report noted that Wave 1 ESCOs may contain more motivated participants that were willing to be early adopters, while at least some Wave 2 nephrologist participants may have been motivated more strongly by gaining exemption from Merit-Based Incentive Payment System (MIPS) requirements and the payment bonus associated with participating in an Advanced APM than by enthusiasm for the model.

The report quoted one ESCO site visit participant as saying, "It’s not even so much the MACRA bonus, it’s just the not getting a pay cut because none of the metrics for MIPS are really applicable at all to a nephrology practice…You end up doing a bunch of meaningless work to try to keep your money the same that doesn’t positively impact outcomes."

The Lewin Group suggested that the CEC experience could inform efforts to develop specialty-oriented accountable care organizations focusing on clinical populations with other chronic conditions such as diabetes, HIV, or congestive heart failure. “The dialysis-dependent ESRD population may be a particularly appropriate population for the development of a specialty-oriented ACO, such as the CEC Model, because the dialysis schedule inherently creates frequent and regular interaction between patients and the at-risk entities (dialysis facilities and nephrologists).”