CMS’s Innovative Value Based Care Solution for Kidney Disease: CKCC - Chronic Kidney Care Contracting

The Centers for Medicare & Medicaid Services (CMS) has developed the Chronic Kidney Care Contracting (CKCC) model to improve the quality of care for patients with chronic kidney disease (CKD). The model is designed to improve the coordination of care among patients, providers, and payers, while also reducing costs associated with the treatment of CKD. The CKCC model is based on the belief that when care is actively coordinated and managed, patients with CKD can receive better health outcomes and lower costs.

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Background 

CKD is a progressive condition that is estimated to affect more than 30 million Americans. As CKD progresses, patients are at higher risk of developing end-stage renal disease, which can require dialysis treatment or a kidney transplant. Treatment for CKD is complex and can be costly, and is often managed by multiple providers, including primary care physicians, nephrologists, and other specialists. As a result, it can be difficult for patients to receive the care they need in a timely and coordinated manner.

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The CKCC model is designed to address these challenges and improve care coordination, while also reducing costs associated with CKD. The model focuses on four core components: 1) care management, 2) patient education, 3) cost savings, and 4) quality improvement. The model is intended to be implemented by Medicare Advantage (MA) plans, which are private health plans that contract with the CMS to provide health care coverage to Medicare beneficiaries.

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Why CKCC now? 

• Patients with chronic kidney disease may experience fragmented care and high-cost treatments that do little to slow disease progression. They also receive limited to no education about their disease and treatment options.
• In the Kidney Care Choices (KCC) Model, groups of nephrologists (kidney doctors) and other kidney care providers and practices come together to take responsibility for patients who have late-stage chronic kidney disease, End-Stage Renal Disease (ESRD), or a kidney transplant. They offer coordinated and seamless care (including dialysis, transplant, and if appropriate, end-of-life care). Additionally, model participants provide education to patients to help empower them to be more active in their care. Patients receive needed services while retaining the freedom to choose providers.
• Through offering higher quality kidney care, the model aims to reduce the number of patients developing kidney failure, have fewer patients receive dialysis in dialysis centers, and increase the number of kidney transplants, so patients can live longer, healthier lives.

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Care Management

The CKCC model focuses on care management, which involves coordinating care among providers and other stakeholders to ensure that patients receive the care they need in a timely and efficient manner. Care management involves creating a comprehensive plan of care for each patient based on their individual needs, which includes identifying and addressing any gaps in care. The plan of care is then shared among providers to ensure that all stakeholders have access to the same information and can coordinate care accordingly.

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Patient Education 

The CKCC model also focuses on patient education, which is designed to help patients better understand their condition and how to manage it. This includes providing patients with information about their medications, lifestyle modifications, and other forms of self-management. The goal of patient education is to empower patients to take an active role in managing their health and to help them make informed decisions about their care.

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Cost Savings

The CKCC model is also designed to reduce costs associated with CKD. This is accomplished through a variety of strategies, including increasing the use of generic medications, reducing emergency department visits, and improving medication adherence. Additionally, the model encourages the use of telehealth technologies and remote patient monitoring to increase access to care and reduce the need for in-person visits.

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Quality Improvement

Finally, the CKCC model focuses on quality improvement, which involves measuring and tracking outcomes to ensure that patients are receiving the best possible care. The model uses a variety of measures, including patient satisfaction surveys, clinical quality measures, and cost measures, to evaluate and improve the quality of care.

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Kidney Care Choices (KCC) Model

Kidney Care Choices (KCC) builds 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 model will have four payment Options: CMS Kidney Care First (KCF) Option, Comprehensive Kidney Care Contracting (CKCC) Graduated Option, CKCC Professional Option, and CKCC Global Option.

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Background

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.

The KCC Model is 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. This Model also aims to delay the need for dialysis and encourage kidney transplantation.

The KCC Model includes four Options:

• CMS Kidney Care First (KCF) Option
• Comprehensive Kidney Care Contracting (CKCC) Graduated Option
• Comprehensive Kidney Care Contracting (CKCC) Professional Option
• Comprehensive Kidney Care Contracting (CKCC) Global Option

Model's Details

The patient is a key component of the Model 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.

Beneficiaries who meet the following criteria will be eligible to be aligned to this Model:

• 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 takes into consideration where a beneficiary receives the majority of their kidney care. When an aligned beneficiary receives a kidney transplant, they 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 they meet the requirements for alignment by virtue of their ESRD.

CMS Kidney Care First (KCF) Option

The KCF Option is open to participation by nephrology practices and their nephrologists and nephrology professionals only, subject to meeting certain eligibility requirements.

Participating nephrologists, nephrology professionals, and nephrology practices receive adjusted capitation payments for managing care of aligned beneficiaries with CKD Stage 4 or 5, and for those on dialysis. These payments are 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 (CKCC) - Graduated, Professional and Global Options

The CKCC Options are open to participation by Kidney Contracting Entities (KCEs). KCEs are required to include nephrologists or nephrology practices and transplant providers, while dialysis facilities and other providers and suppliers are optional participants in KCEs.

In the CKCC Graduated, Professional, and Global Options, KCEs receive capitation payments that are similar to the capitation payments under the KCF Option. KCEs take responsibility for the total cost and quality of care for their patients, and in exchange, can receive a portion or all of the Medicare savings they achieve.

The three CKCC Options will have distinct accountability frameworks:

• CKCC Graduated Option: This payment arrangement 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 Option: This payment arrangement is based on the Professional option of the Global and Professional 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 Option: This payment arrangement is based on the Global option of the Global and Professional Direct Contracting Model – with risk for 100% of the total cost of care for all Parts A and B services for aligned beneficiaries.

Conclusion 

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The CKCC model is an innovative approach to improving the quality of care for patients with CKD. The model focuses on care management, patient education, cost savings, and quality improvement in order to ensure that patients receive the best possible care and that costs associated with CKD are reduced. The model is currently being implemented by Medicare Advantage plans and is expected to provide significant benefits to both patients and providers.

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