In 1972, Congress—moved by the plight of patients dying from lack of access to dialysis—approved full health care coverage through Medicare for people living with end-stage renal disease (also known as ESRD or kidney failure), marking the first time Medicare would cover patients with a specific diagnosis. Almost 50 years later, the needs of this patient population remain complex.
Rates of kidney failure are higher among minorities and low-income populations. Many patients with end-stage renal disease suffer from poorer health outcomes, more comorbidities, and higher mortality rates than the general Medicare population. More than 700,000 Americans need dialysis several times a week or a kidney transplant to stay alive. Due to their complex health needs, patients with kidney disease often require care from multiple providers, which can be difficult if care is uncoordinated.
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During its first decade, the Centers for Medicare and Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMS Innovation Center) explored ways to address the challenges posed by end-stage kidney disease with the goal of improving quality while reducing cost. care for patients with kidney failure. The CMS Innovation Center’s first of its kind initiative was the Comprehensive End-Stage Kidney Disease (CEC) Model of Care, which ran from October 2015 to March 2021 and reduced avoidable care utilization. (such as hospitalizations), improve dialysis care and improve care beyond dialysis.
Prior to the CEC, those providing care to beneficiaries with kidney failure under traditional health insurance had no financial incentive to focus on overall quality of care. For example, a dialysis organization had no direct financial incentive to help recipients avoid unnecessary hospitalizations. The CEC model brought together dialysis clinics, nephrologists, and other providers to create Continuing Care Organizations for End-Stage Kidney Disease, or ESCOs., to coordinate patient care and bear the financial risk for total Medicare Part A and Part B expenses. If ESCOs reduce expenses beyond a certain threshold and meet quality targets, they can share the savings with the CMS. This is called upside risk. For ESCOs that have assumed the downside risk, they must share the losses with CMS if they fail to meet savings and quality targets.
CMS launched the End-Stage Kidney Disease Treatment of Choice Model on January 1, 2021 to encourage home dialysis and transplantation, the optimal treatment for people with kidney disease. Additionally, findings from the CEC model have been incorporated into the Kidney Care Choices (KCC) model, which launched on January 1, 2022. In KCC, nephrologists will be empowered to lead the coordination of care for beneficiaries across the spectrum of care. KCC will focus on Medicare beneficiaries with kidney failure as well as those with advanced chronic kidney disease (stages 4 and 5), and will offer incentives for kidney transplants. We look forward to learning from these models in our efforts to improve healthcare for patients with kidney failure.
Results of the CEC model
The CMS Innovation Center’s CEC model aimed to address many challenges related to kidney disease and its impact on Medicare spending. CMS’s fifth and final evaluation report on the model, released on January 18, found that it had successfully advanced the CMS Innovation Center’s health system transformation goal by improving care delivery. healthcare and reducing Medicare spending. The evaluation found that the CEC model reduced hospitalizations and readmissions. Patients in the model had fewer total hospitalizations, hospitalizations due to ESRD complications, and observation stays. The reductions were relatively small but noteworthy, as more than a quarter of Medicare spending for beneficiaries with ESRD is related to hospitalizations.
Patients in the CEC model saw their dialysis care improve. This included an increase in the number of dialysis sessions, a reflection of participants adding dialysis chairs and offering late shifts for otherwise skipped or missed dialysis appointments. These efforts are important because rescheduling missed appointments is key to avoiding hospitalizations. Additionally, the least preferred method of vascular access for people with kidney failure – long-term use of a catheter – decreased by 6%. Avoidance of catheter use decreases the likelihood of infection, thereby decreasing the likelihood of hospitalizations and other avoidable uses.
Because ESCOs were financially responsible for their aligned population, they had to move from a dialysis-only model of care to one that treats the whole patient. This included appropriate health care utilization and preventive care. CEC recipients had higher rates of primary visits, increased flu vaccinations, and reduced opioid overuse.
Specific to the coordination of care, the ESCOs have taken several measures. Notably, ESCOs have utilized and expanded education efforts to avoid emergency departments (EDs). These efforts included encouraging beneficiaries to contact the ESCO before going to the emergency room and coordinating with hospitals to redirect patients if they could be adequately treated by the dialysis center. Additionally, ESCOs focused on medication management to prevent complications during transitions. These efforts were aimed at reducing hospitalizations. A final form of care coordination effort included risk stratification where recipients most at risk of adverse effects had their care management prioritized. If necessary, these beneficiaries were discussed in interdisciplinary team meetings on how to meet their needs. Respondents from a dialysis organization noted that these efforts were believed to reduce hospitalizations, leading to the use of these teams nationwide.
The ESCOs in the model reduced total Medicare Parts A & B spending by $85 per beneficiary per month, or 1%. These changes were driven by lower payments for acute hospital care, post-acute residential care, and hospitalizations specific to complications of ESRD. The total expense reduction amounts to $217 million in gross savings from October 2015 to December 2020. However, despite the gross savings, the CMS Innovation Center projects a net increase in the cost of Medicare expenses during Accounting for savings payments shared by CMS to model participants.
What can we learn from CEC?
CMS must leverage healthcare innovations to ensure that the ESRD population can receive the best possible care while reducing costly and unnecessary hospitalizations and readmissions. Part of this effort is moving upstream of ESRD to delay and improve dialysis initiation for people with advanced stage 4 and stage 5 chronic kidney disease (CKD), a population not included in the model. Initial CEC. One of the goals of the model is to prevent unplanned initiation of dialysis following an emergency room visit or hospitalization. With this in mind, KCC includes a quality measure for starting dialysis, including starting home dialysis and establishing a permanent form of dialysis access (i.e. a fistula), or the provision of a preventive kidney transplant. By ensuring that people with stage 4 and 5 CKD start dialysis or receive a transplant in this way, CMS can help avoid unnecessary use and associated downstream expenses.
As the CMS Center for Innovation charts the course for the next decade of value-based care that will improve the healthcare system for all patients, it’s critical to take stock of the lessons learned from models like the CEC. As part of a larger CMS Innovation Center strategy, benchmarks for existing models were reviewed when creating benchmarks for future models, including KCC. This was done to increase the likelihood of net savings to the Medicare trust fund.
The CEC model shows how the success of a model cannot be judged solely on its compliance with the statutory criteria for expansion. Often the legacy of a role model continues long after the participation period has ended. The CEC, like many models that no longer work, has provided valuable insights, such as the importance of including beneficiaries with advanced chronic kidney disease in KCC. This insight can guide the creation of stronger subsequent model tests and revise long-held perspectives on healthcare delivery and payment approaches, ultimately having a lasting impact on healthcare transformation.
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