The Kidney Care First (KCF) and Comprehensive Kidney Care Contracting (CKCC) Graduated, Professional, and Global Models will build upon the existing Comprehensive End Stage Renal Disease (ESRD) Care (CEC) Model structure – in which dialysis facilities, nephrologists, and other health care providers form ESRD-focused accountable care organizations to manage care for beneficiaries with ESRD – by adding strong financial incentives for health care providers to manage the care for Medicare beneficiaries with chronic kidney disease (CKD) stages 4 and 5 and ESRD, to delay the onset of dialysis and to incentivize kidney transplantation. The design of these models likewise draws from the recently announced Primary Care First and Direct Contracting models.
The current Medicare payment system encourages in-center hemodialysis as the default treatment for patients beginning dialysis. According to the Government Accountability Office, in-center hemodialysis is the most common type of dialysis and was used by about 88 percent of dialysis patients in 2016. 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, often the result of underlying disease complications and multiple co-morbidities.
CMS announced four optional kidney care models:
- Kidney Care First (KCF) Model
- Comprehensive Kidney Care Contracting (CKCC) Graduated Model
- Comprehensive Kidney Care Contracting (CKCC) Professional Model
- Comprehensive Kidney Care Contracting (CKCC) Global Model
These models are designed to help health care providers reduce the cost and improve the quality of care for patients with late-stage chronic kidney disease and ESRD. These Models also aim to delay the need for dialysis and encourage kidney transplantation.
The patient is a key component of the Models’ design. The tendency now is for patients with kidney disease to follow the most expensive path, with little prevention of disease progression and an unplanned start to in-center hemodialysis treatment. By increasing education and understanding of the kidney disease process, aligned beneficiaries may be better prepared to actively participate in shared decision making for their care.
The beneficiary alignment process will be the same for the KCF and CKCC Models. Beneficiaries who meet the following criteria will be eligible to be aligned to these Models:
- Medicare beneficiaries with CKD stages 4 and 5.
- Medicare beneficiaries with ESRD receiving maintenance dialysis.
- Medicare beneficiaries who were aligned to a KCF practice or KCE by virtue of having CKD stage 4 or 5 or ESRD and receiving dialysis that then receive a kidney transplant.
Alignment will take into consideration where a beneficiary receives the majority of his or her kidney care. When an aligned beneficiary receives a kidney transplant, he or she will remain aligned to the model participant for three years following a successful kidney transplant or until the time a kidney transplant fails, at which point the beneficiary could be re-aligned if he or she meets the requirements for alignment by virtue of his or her ESRD.
Kidney Care First (KCF) Model
In the KCF 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 Kidney Care First Model will be open to participation by nephrology practices and their nephrologists only, subject to meeting certain eligibility requirements.
Participating nephrologists and nephrology practices will receive adjusted capitated payments for managing care of aligned beneficiaries with CKD Stages 4 or 5, and for those on dialysis. These payments will be adjusted on the basis of health outcomes and utilization compared to both the participants’ own experience and national standards, and also performance on quality measures. In addition, KCF practices will receive a bonus payment for every aligned beneficiary who receives a kidney transplant, with the full amount of the bonus paid over three years following the transplant provided the transplant remains successful.
Comprehensive Kidney Care Contracting - Graduated, Professional and Global Models
The CKCC Models include the Graduated, Professional, and Global Models—in which capitated payments will be similar to the capitated payments under the KCF Pathway, but the Kidney Contracting Entities – which consist of nephrologists, transplant providers, and other health care 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.
Kidney Contracting Entities (KCEs) participating in the Comprehensive Kidney Care Contracting Models are required to include Nephrologists or nephrology practices and transplant providers, while dialysis facilities and other providers and suppliers are optional participants in KCEs.
As in the KCF Model, KCEs will receive adjusted payments for managing beneficiaries with CKD Stages 4 and 5, and ESRD, and along with the kidney transplant bonus payment.
The CKCC Models will have three distinct accountability frameworks:
- CKCC Graduated Model: This model is based on the existing CEC Model One-Sided Risk Track – allowing certain participants to begin under a lower-reward one-sided model and incrementally phase in to greater risk and greater potential reward.
- CKCC Professional Model: This payment arrangement is based on the Professional Population-Based Payment option of the Direct Contracting Model – with an opportunity to earn 50% of shared savings or be liable for 50% of shared losses based on the total cost of care for Part A and B services.
- CKCC Global Model: This payment arrangement is based on the Global Population-Based Payment option of the Direct Contracting Model – with risk for 100% of the total cost of care for all Parts A and B services for aligned beneficiaries.
The 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. Health care providers interested in participating will apply to participate in the fall of 2019, and if selected, begin model participation in 2020. However, financial accountability will not begin until 2021. During 2020, or Year 0, model participants will focus on building necessary care relationships and infrastructure.
For any questions, please email the KCF and CKCC model teams at KCF-CKCC-CMMI@cms.hhs.gov.