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RPA Comments on ACO Proposed Rule

Creation/Revision Date: June 07, 2011

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Donald Berwick, MD 
Centers for Medicare and Medicaid Services 
Department of Health and Human Services 
Room 445-G, Hubert H. Humphrey Building 
200 Independence Avenue, SW 
Washington, DC 20201 

Re: CMS-1345-P: Medicare Program; Shared Savings Program: Accountable Care Organizations; Proposed Rule 

Dear Dr. Berwick: 

The Renal Physicians Association (RPA) is the professional organization of nephrologists whose goals are to ensure optimal care under the highest standards of medical practice for patients with renal disease and related disorders. RPA acts as the national representative for physicians engaged in the study and management of patients with renal disease. We are writing to provide comments on the proposed rule creating Accountable Care Organizations (ACOs) as part of the Medicare Shared Savings Program. 

In general, while RPA appreciates the difficulty of CMS’ task in implementing the limited legislative mandate to create ACO’s, and we recognize the unique level of complexity involved with developing this particular rule, we also regret the fact that CMS did not do more to facilitate the development of a kidney disease ACO. RPA along with other stakeholders in the kidney care community strongly believe that there are a host of structural features of the ESRD care delivery system and characteristics of the ESRD patient population that ideally qualify kidney disease for a specialty-specific ACO model. Accordingly, we believe that CMS’ determination to not facilitate the development of a kidney disease ACO is an opportunity lost. 

RPA’s comments will discuss the following issues:  

Implications for ESRD Patient Care in General ACOs
Suitability of Existing Structures for Kidney Disease Integrated Care Models
ESRD Demonstration Project Experience
Implications for ESRD Patient Care in General ACOs

RPA completely supports the three primary aims of Congress and CMS in creating ACOs, namely enhancing care delivery to individual patients, improving population health, and promoting greater cost-efficiency in the delivery of patient care, and we believe that for most patient populations, availability of an ACO model of care delivery has the strong potential to achieve those aims. However, as the Agency knows, the ESRD patient population and kidney care community are subject to a completely unique set of circumstances with regard to the vulnerability of the ESRD patient’s health and the quality of care delivered, and that as a result special attention must be paid to the care delivered to Medicare’s ESRD beneficiary patient population. 

In this spirit, RPA is concerned that if ESRD patients are enrolled in a non-kidney specific, or “general” ACO without appropriate safeguards, the impact on their care could be detrimental. While some general ACOs will likely be able to create the infrastructure necessary to effectively treat ESRD patients and help those patients thrive, we believe this will be the exception rather than the rule. Further, we are concerned that the kidney disease-specific expertise and care delivery structure in many general ACOs will be limited, and as a result the care delivered to ESRD patients within those entities will be compromised. As CMS is well aware, gaps in care coordination and renal-specific expertise for dialysis patients can not only have a devastating effect on individual patient outcomes, but can also result in substantial and unnecessary Medicare program expenditures. 

RPA therefore urges CMS to create a kidney disease-specific pathway for ESRD patients to benefit from the advantages offered by integrated care models without the risk of having these patients enrolled in ACO plans unsuited to the delivery of their care. 

Suitability of Existing Structures for Kidney Disease ACO Development 

As noted, RPA believes that there are numerous features of the ESRD care delivery structure and characteristics of the kidney patient population that make kidney disease care uniquely suited for implementation of a kidney disease integrated care model. Among these distinctive aspects of the kidney disease care delivery milieu are: 

• The well-defined nature of ESRD patient population: While the certification process for patients with ESRD is not perfect, it does accurately identify the vast majority of patients with ESRD, and once these patients are certified with ESRD are seen by their nephrologist anywhere from once to four or more times a month. RPA would posit that no Medicare patient sub-population is seen by their providers of care more often than ESRD patients; 

• The integrated system of providers necessary to appropriately care for ESRD patients: Included among these caregivers are nephrologists, nurse practitioners, physician assistants, clinical nurse specialists, dieticians, social workers, and dialysis technicians. Further, the Conditions for Coverage for ESRD Facilities and guidelines for the monthly capitated payment (MCP) mandate the coordination of ESRD patient care by dialysis facility leadership and nephrologists. Again, RPA would note that this is a care coordination model that is infrequently replicated outside of the kidney disease arena; 

• Familiarity with alternative and innovative payment models; Nephrologists and dialysis facilities have received capitated and bundled reimbursements, respectively, for the better part of several decades providing experience with payment systems likely to be used in an integrated care delivery model; 

• Experience with clinical data gathering structures: The detailed data gathering on ESRD patients provided by the United States Renal Data System (USRDS) has been in place since 1988; 

• Nephrology experience with development of clinical performance measures: The nephrology community has extensive experience with the development and reporting of clinical performance measures; in fact, RPA is the convening organization for the Kidney Disease Work Group of the AMA’s Physician’s Consortium for Performance Improvement (PCPI) and is also a member of the National Quality Forum (NQF); and 

• Kidney provider experience with performance measurement: The kidney care provider community has as much or more experience with having its performance measured than any other group of disease-specific providers, going back to the ESRD Core Indicators project, which assessed the association between quality improvement interventions and changes in the adequacy of hemodialysis between 1993 and 1996. 

There are two specific aspects of the current ESRD patient care delivery and reimbursement model that RPA believes must be maintained as a kidney disease specific integrated care model is developed. First, nephrologists must have a leadership role in the development and administration of such an entity. Such a leadership role will help ensure that patients will benefit from the clinical expertise of the nephrologist to the greatest extent possible. Second, the monthly capitated payment for nephrologists’ reimbursement must be maintained separately from all other payment mechanisms associated with the integrated care model, in order to preserve both the nephrologist-dialysis patient relationship, and to maintain nephrologist autonomy. 

ESRD Demonstration Project Experience

As the Agency knows, the ESRD Disease Management Demonstration Project was conducted from 2006-2010, and while only the results for the first three years of the project are currently available, they are encouraging. In short, they indicate: (1) improvement in hospitalization, mortality, and transplantation related measures; (2) improvement in patient outcomes and processes of care; (3) improvement in patient quality of life, experience, and satisfaction measures; and (4) a reduction in the overall cost of care by 5.1 percent when compared to traditional fee-for-service (FFS) expenditures. 

While the scope of the ESRD Demonstration Project was limited, it is reflective of the potential of an integrated care delivery model to improve individual patient care, enhance the care provided to the nation’s Medicare ESRD beneficiary patient population as a whole, and to achieve more efficient use of Medicare’s fiscal resources. RPA urges CMS to implement the lessons learned from the ESRD Demonstration Project in the development of an integrated care delivery model for ESRD patients. 

As always, we welcome the opportunity to work collaboratively with CMS in its efforts to improve the quality of care provided to the nation’s kidney patients, and we stand ready as a resource to CMS in its future endeavors. Any questions or comments regarding this correspondence should be directed to RPA’s Director of Public Policy, Rob Blaser, at 301-468-3515, or by email at


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Ruben L. Velez, M.D. 

Renal Physicians Association

1700 Rockville Pike
Suite 220
Rockville, MD 20852

Phone: 301-468-3515
Fax: 301-468-3511

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