Kidney News June 2016 8#6 : Page 1
June 2016 | Vol. 8, Number 6 New Physician Pay Program May Give ESCOs a Boost By Bridget M. Kuehn Inside NIH Director Interview National Center for Complementary and Integrative Health Director on what kidney professionals should know about mind-body approaches to pain, herbal supplements, and more $ N ew value-based payment in-centives from the Centers for Medicare and Medicaid Ser-vices (CMS) may entice more nephrolo-gists and possibly dialysis organizations to participate in ESRD Seamless Care Organizations (ESCOs). CMS recently announced a second round of applica-tions for participation in ESCOs; those accepted would begin the model in January 2017. A proposed rule pub-lished in April pro-vided a first peek at how CMS’ new system for pay-ing physicians might work, including for physicians participating in “Alternative Payment Mod-els” (APMs) such as ESCOs. The Medicare Ac-cess and CHIP Reau-thorization Act of 2015 (MA-CRA) repealed the Sustainable Growth Rate formula previously used to establish Medicare payments for physicians. It provides incentives for doctors to partici-pate in care delivery models that count as “Advanced APMs,” which allow them to earn bonus payments and avoid poten-tial Medicare reimbursement cuts. Un-der the proposed rule, nephrologists who participate in ESCOs on the “Large Di-alysis Organization” track would count as participating in an Advanced APM. “It will definitely incentivize partici-pation in ESCOs,” said Suzanne Wat-nick, MD, a member of the ASN Public Policy Board and a professor at Oregon Health & Science University in Portland. Thirteen dialysis organizations cur-rently participate in ESCOs, the Com-prehensive ESRD Care (CEC) Model launched in 2015. The CEC Model was intended to help evaluate and improve ESRD care. In the program, dialysis clin-ics, nephrologists, and other care provid-ers partner to coordinate care for a popu-lation of Medicare beneficiaries with ESRD. Participating organizations reap the benefits of more streamlined and im-proved care for the population by sharing a portion of the savings to Medicare. Par-ticipants in the Large Dialysis Organiza-tion track, those with 200 or more di-alysis facilities, also are liable for losses if they fail to yield cost savings. Small dialy-Continued on page 2 Findings Study urges increased awareness and education about preemptive transplant prior to dialysis initiation Fellows Corner My Journey to Nephrology, by Silvi Shah International Collaboration ASN, the International Society of Nephrology, and the European Renal Association--European Dialysis and Transplant Association announce declaration of collaboration Nephrology Goes All-In: An Update on the Match By Michael J. Ross and Kurtis Pivert Policy Update circumscribed. NRMP’s final Match data report released on March 7 noted that a total of 140 programs offered 158 training tracks (Clinical, Clinical Research, Research, and Other) and a record 466 fellowship positions for appointment year (AY) 2016. All-In’s first year was therefore quite success-ful in increasing the number and per-centage of nephrology fellowship posi-tions offered through the Match. Despite an increase in the overall number of candidates choosing neph-rology (298, up from 252 in AY 2015), the number of non-US international Continued on page 3 I n the first year of the All-In Neph-rology Match, the number of par-ticipating programs and training tracks rose to the highest level since the specialty joined the National Resi-dency Matching Program’s (NRMP’s) Medical Specialties Matching Pro-gram. Although there was a slight increase in applicants choosing neph-rology, the recent trend of increasing numbers of unfilled positions and programs continued. Nearly 60 per-cent of training tracks and over 40 percent of positions were left open on Match day. The vast majority of nephrology training programs participated in All-In and potential nonparticipation was A patient, a fellow, and an MD on advocating for the Living Donor Protection Act, plus will 21st Century Cures advance? MOC Update ABIM continues to tweak MOC
New Physician Pay Program May Give ESCOs A Boost
Bridget M. Kuehn
New value-based payment incentives from the Centers for Medicare and Medicaid Services (CMS) may entice more nephrologists and possibly dialysis organizations to participate in ESRD Seamless Care Organizations (ESCOs). CMS recently announced a second round of applications for participation in ESCOs; those accepted would begin the model in January 2017.
A proposed rule published in April provided a first peek at how CMS’ new system for paying physicians might work, including for physicians participating in “Alternative Payment Models” (APMs) such as ESCOs.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the Sustainable Growth Rate formula previously used to establish Medicare payments for physicians. It provides incentives for doctors to participate in care delivery models that count as “Advanced APMs,” which allow them to earn bonus payments and avoid potential Medicare reimbursement cuts. Under the proposed rule, nephrologists who participate in ESCOs on the “Large Dialysis Organization” track would count as participating in an Advanced APM.
“It will definitely incentivize participation in ESCOs,” said Suzanne Watnick, MD, a member of the ASN Public Policy Board and a professor at Oregon Health & Science University in Portland.
Thirteen dialysis organizations currently participate in ESCOs, the Comprehensive ESRD Care (CEC) Model launched in 2015. The CEC Model was intended to help evaluate and improve ESRD care. In the program, dialysis clinics, nephrologists, and other care providers partner to coordinate care for a population of Medicare beneficiaries with ESRD. Participating organizations reap the benefits of more streamlined and improved care for the population by sharing a portion of the savings to Medicare. Participants in the Large Dialysis Organization track, those with 200 or more dialysis facilities, also are liable for losses if they fail to yield cost savings. Small dialy- sis organizations were not asked to take on this level of risk in CMS’ first round of requests for ESCO participation—but those small dialysis organizations’ ESCOs would not count as Advanced APMs under the new proposed rule.
Despite the lower risk requirements, the hurdles to participation in the ESCO program proved too much for many small dialysis organizations, and only one—the New York City–based Rogosin Institute— chose to participate. Many didn’t have the resources to create necessary infrastructure or provide enough personnel to monitor patient care, Watnick said. Small organizations were also concerned that the outcomes they were being graded on weren’t available upfront, she noted.
“It was going to be hard for small organizations with the resources they had,” Watnick said. “People weren’t clear they could realize a financial benefit.”
“The challenges have been numerous for us and all [ESCOs],” said Jeffrey Silberzweig, MD, Rogosin’s chief medical officer. The biggest challenges were creating the infrastructure, figuring out the role of care coordinators, and working with staff inside Rogosin and with specialists who see its patients elsewhere to reconcile patient medications. But he said he and his colleagues have found the effort worthwhile.
“It’s really affording us an opportunity to evaluate the care we are providing our patients and to ensure we are providing the best level of care we can,” Silberzweig said.
Large dialysis organizations like DaVita HealthCare Partners, based in Denver, Colorado, were drawn to the program because they were confident that their experience in integrated health care would help them be successful at meeting CMS’ triple aim: improving patient experience, population health, and reducing health care costs.
“The model wasn’t perfect, but we felt it was an opportunity to prove we could achieve the triple aim,” said Stephen McMurray, MD, medical director of DaVita’s integrated care wing, Village Health.
The ESCO model provides new resources for meeting patients’ clinical and social needs inside and outside of the health care setting, said Nathan Lohmeyer, DaVita’s Vice President of Government Programs.
“We think the model of care that can be provided through the [CMS ESCO program] is phenomenal,” Lohmeyer said.
But success relies on full participation of nephrologists and other members of the care team, said McMurray. “It just doesn’t work if the whole team isn’t involved,” he said.
Financial incentives in the MACRA rule as well as changes to the ESCO model are likely to entice more nephrologists and dialysis organizations to join the program, Watnick said.
Under the MACRA rule, beginning in 2019 physicians will be reimbursed either through the Merit-based Incentive Payment System (MIPS) or through participation in an Advanced APM. Physicians participating in Advanced APMs, entities that take on financial risk as well as benefit and meet certain other financial, electronic health record (EHR), and quality criteria, would be eligible for their Medicare reimbursement plus a 5% bonus, Watnick explained. Physicians participating in MIPS could see their reimbursement increase—or decrease—4% in 2019 and up to 9% in subsequent years depending on their performance on four criteria (quality, clinical practice improvement activity, resource use, and EHR use).
Large dialysis organizations participating in ESCOs automatically qualify as an APM, according to the MACRA rule. Small organizations must take on some risk in order to qualify as an advanced APM, Silberzweig noted.
“We do think it’s a good outcome for our participating nephrologists that our ESCO will be classified as an Advanced APM,” said Lohmeyer. “The opportunity to participate in the Advanced APM track and possibly earn a bonus is a nice benefit.”
But Lohmeyer said it wasn’t clear whether these incentives for nephrologists alone would be enough to encourage organizations to form an ESCO. He noted that geography, startup costs, and other factors may make forming an ESCO impossible for some organizations.
Silberzweig noted that 2 to 3 small dialysis organizations have expressed interested in joining in the second round of the program.
CMS is accepting its second round of applications for participation in ESCOs through July 15. This time it has provided more detailed information about performance measures upfront, according to Watnick.
“It’s not 100% clear, but it’s a lot clearer than in the first round,” she said.
Plus, dialysis organizations participating in the second round of ESCOs will have the advantage of learning from experienced programs, Silberzweig said. He also noted that CMS has been very responsive to his organization’s concerns and has been willing to adapt the program.
“It makes us very enthusiastic about continuing to work with them,” he said.
Many questions remain about the final form the MACRA rule will take. Among them are whether MACRA payments will start in 2019 based on 2017 performance as proposed or be pushed back, noted Lohmeyer. It’s also unclear how the agency will calculate bonus eligibility for nephrologists participating in an ESCO, he said.
“CMS encourages and welcomes all interested parties to submit their suggestions on the proposed rule during the comment period, and is listening to the feedback we are receiving,” said a CMS official in an emailed statement.
This provides an opportunity for nephrologists and dialysis organizations to really shape the MACRA rule to make sure their patients have access to the best care, said Watnick. For example, she said, it should be easy for patients to receive kidney transplants or palliative care if that’s the best choice for them.
“We are in a period where we can impact what MACRA will look like,” she said. “Patients with ERSD are some of the most socially and economically disadvantaged patients and are among the most chronically ill patients. Any new changes have to be patient-centric and improve not just quantity of life but also quality of life.”
CMS is accepting comments on the MACRA rule through June 27.
Nephrology Goes All-In: An Update On The Match
Michael J. Ross and Kurtis Pivert
In the first year of the All-In Nephrology Match, the number of participating programs and training tracks rose to the highest level since the specialty joined the National Residency Matching Program’s (NRMP’s) Medical Specialties Matching Program. Although there was a slight increase in applicants choosing nephrology, the recent trend of increasing numbers of unfilled positions and programs continued. Nearly 60 percent of training tracks and over 40 percent of positions were left open on Match day.
The vast majority of nephrology training programs participated in All- In and potential nonparticipation was circumscribed. NRMP’s final Match data report released on March 7 noted that a total of 140 programs offered 158 training tracks (Clinical, Clinical Research, Research, and Other) and a record 466 fellowship positions for appointment year (AY) 2016. All-In’s first year was therefore quite successful in increasing the number and percentage of nephrology fellowship positions offered through the Match.
Despite an increase in the overall number of candidates choosing nephrology (298, up from 252 in AY 2015), the number of non-US international medical graduates (IMGs) fell to its lowest level since Nephology entered the Match (100 candidates, down from 331 in AY 2009). This decline is of concern because IMG physicians have comprised a majority of nephrology fellowship candidates over the past 8 years. Numbers of candidates applying to nephrology training programs from other educational backgrounds were stable (US medical graduates and osteopaths) or rose slightly (US IMGs) over AY 2015.
The increased participation and rebound in candidates doesn’t obscure the shrinking pipeline of candidates choosing careers in nephrology. For every fellowship position offered in AY 2016, there were only 0.60 candidates, a marked decrease from 4 years ago when there were 1.1 candidates per fellowship position. The Match rate remained flat at 92.6 percent.
ASN Council has approved multiple initiatives to increase interest in nephrology careers at every stage of the educational continuum, such as the Kidney STARS and Kidney TREKS programs. ASN’s ongoing nephrology workforce research collaboration with George Washington University has provided insights into the current and future generations of nephrologists, and informed the kidney community on trends for specialty researchers identified as “in transition.” Recent publications have also highlighted the need for nephrology programs to consider resizing their training programs to optimize the balance between supply and demand for nephrologists, which should lead to an improved job market for graduating fellows.
Monitoring the Match
After the declining participation in the nephrology Match, the ASN Council unanimously approved an All-In Policy for the Nephrology Match in 2015. As the official sponsor of the Nephrology Match, ASN believes All-In is the best approach for the specialty in the long term and helps ensure all candidates: 1) have fair and equal access to programs, and 2) can examine the full range of training opportunities before making a final decision. Moreover, the All-In Policy provides programs with an equitable system to evaluate candidates on an orderly and transparent schedule.
As part of the move to All-In, ASN established the ASN Match Oversight Task Force to monitor outcomes, assess participation, and make recommendations to ASN Council (Table 1) . Convened in December 2015, the Task Force reviewed available data from NRMP and the Electronic Residency Application Service (ERAS) and identified a limited number of programs potentially nonparticipating in ASN’s All-In Policy. ASN is following up with a small number of programs to discuss their participation in the Match, and solicit their input and concerns about the process and recommendations on how ASN can better support their efforts in training the next generation.
New features in the AY 2017 Application Cycle
As announced in 2015, programs participating in the All-In Nephrology Match will be listed in, and have access to, ERAS starting with the AY 2017 application cycle (Table 2). Because ERAS and NRMP have different processes and timelines for administering their Match responsibilities, ASN is asking programs to sign a memorandum of understanding (MOU) to provide ERAS the information it needs to verify programs/tracks participating in the AY 2017 All-In Nephrology Match. Programs and training tracks that enter into the MOU by Wednesday, June 15, 2016, at 5 p.m. EDT will be available for candidates to apply to when ERAS opens on Friday, July 1. Programs that enter into the MOU after June 15 will be listed, but ERAS will not inform candidates of any additions.
The ASN Match Oversight Task Force recommended, and ASN Council approved, extending eligibility for ASN benefits to participating programs, effective with the AY 2017 application cycle (Table 3). Additionally, ERAS has agreed to inform PGY-3 internal medicine residents that the Nephrology Match follows an All-In Policy. A series of emails will direct residents to ASN resources that can inform their consideration of additional subspecialty training and a career in nephrology. Finally, an annual census of fellows reporting for training in July will provide definitive data on nephrology training programs.
ASN’s move to All-In will be followed by Infectious Diseases and Sleep Medicine this year, and other specialties are considering implementing similar policies. The level playing field All-In offers candidates in the Residency Match could someday be the norm for all specialties, giving candidates the best opportunity to make informed and unpressured choices about their careers.
For more information about the All-In Nephrology Match, please visit www.asn-online.org/education/training/match/ or contact firstname.lastname@example.org.
Michael J. Ross, MD, FASN, is Chair of the ASN Match Oversight Task Force, Associate Professor, Director of the Nephrology Fellowship Program at the Icahn School of Medicine at Mount Sinai, and Chief of the Division of Nephrology at the James J. Peters VA Medical Center, in New York, NY.