WASHINGTON, D.C. – June 6, 2011,  Dialysis Patient Citizens (DPC) – a nationwide, non-profit, patient-led dialysis advocacy organization – recently asked the Centers for Medicare and Medicaid Services (CMS) to reconsider several provisions within the Proposed Rule for the Medicare Shared Savings Program: Accountable Care Organizations to ensure that kidney disease patients  are not excluded from federal care coordination efforts that have the potential to improve clinical outcomes, increase patients’ quality of life and lower health care costs.

“As a patient-led organization dedicated to improving the lives of patients, DPC strongly supports  efforts to improve health care integration and coordination and very much wants to see providers rewarded for providing high quality care,” said Hrant Jamgochian, Executive Director of Dialysis Patient Citizens.  “At the same time, we are concerned that several provisions in the proposed rule may incentivize ACOs to exclude beneficiaries with high cost chronic conditions, such as kidney disease.”

Treatment for chronic diseases, such as chronic kidney disease (CKD) and end stage renal disease (ESRD), is currently the leading expenditure in the United States health care system, accounting for 75 cents of every health care dollar spent. In the Medicare and Medicaid systems alone, that figure increases to more than 90 cents of every dollar spent.  ESRD patients, in particular, often see multiple physicians and take several medications for their conditions. A more integrated system has the potential to improve patient care and reduce health care costs.

While DPC is encouraged by CMS’s emphasis on patient choice and commitment to rewarding high-quality providers, the organization has several specific concerns regarding the Proposed Rule in its current form. First, DPC expressed concern over CMS’s decision to exclude specialists and non-primary care providers from forming ACOs, as nephrologists often serve as the primary health care provider for ESRD patients and may be in the best position to coordinate their care. Many of these patients also spend several hours a week in dialysis facilities, where the opportunity for intervention is significant. Therefore,  the decision to exclude these providers, as well as others from forming ACOs, may not only limit who  will be rewarded for providing quality care, but may cause some to miss some of the best opportunities to incentivize care that improves health and reduces costs.  

DPC also expressed concern regarding the proposal to retrospectively assign patients to each ACO, as this could incentivize physicians to identify the healthiest patients and avoid high-cost, high-risk beneficiaries.  In addition, under the Proposed Rule, ACOs are protected from risks on any patient’s costs exceeding $100,000. Annual treatment costs for an individual ESRD patient can often exceed $70,000, meaning this provision could limit a physician’s incentive to spend the necessary time and money to provide the highest quality of care.

Finally, DPC urged CMS to ensure the Shared Savings Program does not deter ACOs from providing transplants to patients with kidney failure. While transplants are expensive procedures, the health care costs for transplant recipients decreases in the following years and can make a tremendous impact on a patient’s quality of life. ACOs should not be penalized for such short-term cost increases that improve long-term health outcomes, especially when there is such significant cost savings in the future.
DPC also encouraged CMS to move forward with additional opportunities outside of the ACO Proposed Rule to increase care coordination for ESRD patients. The Center for Medicare and Medicaid Innovation (CMMI) can build upon recent CMS demonstrations by several dialysis organizations that showed how integrated care models can improve clinical outcomes, lower costs and increase patient quality of life.

“DPC is committed to increasing access to quality care and improving the lives of dialysis patients,” said Jamgochian. “We respectfully urge consideration of our comments and stand ready to work with CMS and the kidney community to ensure that ESRD patients will benefit from new coordinated care efforts.”

>Read the Full Letter to CMS Here