News | Payment Models

Mandatory models among 6 newly proposed Medicare demos

News | Payment Models

Mandatory models among 6 newly proposed Medicare demos

  • A mandatory bundled payment model for radiation oncology would enroll group practices, hospital outpatient departments and freestanding radiation centers in randomly selected regions.
  • The mandatory End-Stage Renal Disease Treatment Choices model would enroll provider participants treating about half of all Medicare ESRD beneficiaries
  • Four voluntary models would use either one- or two-sided risk to incentivize care plans that delay the need for dialysis and encourage kidney transplantation.

Mandatory models for kidney care and oncology were among six new Medicare payment models proposed in mid-July.

The End-Stage Renal Disease Treatment Choices (ETC) model would be mandatory for certain areas of the country, as would a radiation oncology (RO) bundled payment model. Four other kidney care models would be voluntary.

According to a fact sheet from the Centers for Medicare & Medicaid Services (CMS), the RO bundled payment model:

  • Launches Jan. 1, 2020, and runs for five years
  • Mandates participation of group practices, hospital outpatient departments and freestanding radiation centers in randomly selected areas of the country
  • Provides a bundled payment for 90-day episodes of radiation therapy for 17 types of cancer
  • Replaces regular Medicare fee-for-service payments
  • Allows providers to keep any savings if spending is less than the bundled payment, subject to quality and patient experience measures
  • Requires providers to cover costs above the payment amount
  • Features site-neutral payments
  • Qualifies as an Advanced Alternative Payment Model (APM) and a Merit-based Incentive Payment System APM
  • Splits payments into a professional component and a technical component

Mandatory kidney care model aims to boost dialysis, transplantation rates

According to a CMS fact sheet, the mandatory ETC kidney care model:

  • Adjusts certain Medicare payments to selected end-stage renal disease (ESRD) facilities and clinicians who manage ESRD beneficiaries
  • Increases or cuts payment rates based on the shares of patients using home dialysis and receiving kidney and kidney-pancreas transplants
  • Adjusts Medicare payments for the first three years of the model for home dialysis and dialysis-related services
  • Risk-adjusts the home dialysis and transplant rates used for performance payment changes
  • Requires participation by providers in geographic areas that encompass about half of Medicare ESRD beneficiaries
  • Operates from Jan. 1, 2020, to June 30, 2026
  • Does not affect payments for ESRD facilities and managing clinicians if they are not in a participating region
  • Compares model participants with nonparticipants to determine how the model affects care quality
  • Matches model participants and comparators on variables, such as Medicare spending in the years prior to the model 
  • Excludes some low-volume providers

Voluntary models also seek to enhance kidney care

The four newly proposed voluntary models are the Kidney Care First (KCF) model, the Comprehensive Kidney Care Contracting (CKCC) Graduated model, the CKCC Professional model and the CKCC Global model, according to a CMS fact sheet.

They are designed to help healthcare 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 KCF model:

  • Is open only to nephrology practices and their nephrologists
  • Provides participating nephrology practices with adjusted fixed payments on a per-patient basis for managing the care of patients with late-stage chronic kidney disease and ESRD
  • Adjusts payments based on health outcomes and utilization compared with both past performance and national standards, as well as performance on quality measures
  • Provides a bonus payment to practices for each aligned patient who receives a kidney transplant if the patient remains healthy for up to three years after the surgery
  • Starts financial accountability in 2021
  • Operates from Jan. 1, 2020, through Dec. 31, 2023 but may extend for up to two more years

The CKCC models:

  • Include the Graduated, Professional and Global variations
  • Provide capitated payments similar to the KCF model
  • Place responsibility on nephrologists, transplant providers and other healthcare providers for the total cost and quality of care for their patients
  • Give providers a portion of the Medicare savings they achieve
  • Start financial accountability in 2021
  • Operate from Jan. 1, 2020, through Dec. 31, 2023, but may extend for up to two more years

The Graduated model would allow certain participants to begin under a lower-reward, one-sided model and incrementally move into greater risk with greater potential rewards.

The Professional model would allow participating providers to earn 50% of shared savings while being liable for 50% of shared losses based on the total cost of care for Part A and Part B services.

The Global model would include 100% risk for the total cost of care for all Part A and Part B kidney care services for aligned beneficiaries.

Public comments are due within 60 days of publication of the rules in the Federal Register.

About the Authors

Rich Daly, HFMA senior writer/editor

is based in the Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

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