CMS demonstration project
VillageHealth pleased with ESRD program
Traditionally, CMS has not allowed Medicare beneficiaries with end-stage renal disease (ESRD) to enroll in Medicare Advantage (MA) plans, but an ongoing demonstration project is testing the effectiveness of DM models in improving quality of care for ESRD patients. CMS’ ESRD Disease Management Demonstration includes organizations that provide services for dialysis patients, such as:
The organizations receive the same risk-adjusted ESRD capitation payment as the MA program overall—with separate rates for dialysis, transplant, and posttransplant modalities. The ESRD payment amount can be reduced by 5% depending on performance on quality measures, according to CMS. Kerry Willis, PhD, senior vice president of scientific activities at the National Kidney Foundation in New York City, says CMS spends billions on dialysis, and the federal agency has been focusing on improving dialysis care. In fact, studies have shown the average dialysis patient incurs costs of about $70,000 per year. (See “Pharmacy program with DM component targets CKD” in the January DMA.)
“There has been a huge upsurge the last 10 years trying to understand and trying to really constitute the best practices and the best therapies in this population,” Willis says.
Health plans usually only pay for dialysis for a short time before Medicare picks up the tab. Willis says some private insurers have been implementing proactive programs to catch at-risk patients before they spiral into dialysis. These kinds of interventions are being tried by several healthcare organizations that are hoping to stop the deterioration to ESRD.
“Where health plans have been very active is in trying to devise strategies to reduce the progression of kidney disease so they don’t wind up with patients on dialysis,” Willis says, adding that about 70% of patients on dialysis regress to that level because of uncontrolled type 2 diabetes or hypertension, and 40% of patients with uncontrolled type 2 diabetes have kidney damage. Many with ESRD did not get their BP or blood sugar under control, and that led them on the road to dialysis, he says.
DaVita, through its VillageHealth program, has been serving about 420 Scan Health Plan members with ESRD since the start of the project at the beginning of 2006. Chris Mayne, regional operations director at VillageHealth in San Bernardino, CA, says DM programs for the ESRD population make sense.
Mayne says CMS recently sent DaVita data from the first 18 months of the project (January 2006–June 2007). “We learned we do make a difference in the outcomes that are most meaningful in that population,” he says about the demonstration data, which have not been publicly released by CMS.
VillageHealth is offering the same programs it provides to its other ESRD patients, including a 24/7 nurse case manager, who Mayne says is the primary DM arm of the programs. The case manager has a portfolio of patients with whom he or she meets at least once per month.
Mayne says one reason DM is appealing to this population is that many ESRD patients visit dialysis facilities three times per week for three or four hours. Having the patients at the centers makes it easier for the case managers to stay connected with patients, he says.
“That means that we know, for the most part, where they are, so it’s easier to meet with them and do what we can do to help them,” Mayne says. He says DaVita’s programs include intervention, care coordination, and patient activation. The intervention program helps ESRD patients handle their other health problems and comorbidities, such as diabetes and hypertension.
ESRD patients may have various doctors’ appointments because of these additional health problems. The case managers in the project help the patients coordinate their appointments.
“The VillageHealth nurse is at the center of it. It’s coordinating with the patients, coordinating with the doctors, and coordinating with the dialysis facility,” Mayne says.
Patient activation begins with engagement, which starts with building a rapport with the patients. Gaining trust can take time.
Beyond building the patient’s trust, the case managers also need to build relationships with physicians and show them that the ESRD program is valuable.
“From there, it’s learning what is the right methodology and frequency of communication they prefer. Not every physician is the same in that manner. But we’re all here to get the best results for the patient so, in the end, it ends up being one big clinical team, and that includes the dialysis facility as well,” Mayne says.
The health status of ESRD patients makes care difficult. “The biggest challenge is that the patients have so many things that are going on with them clinically. It’s how do you focus on the really important few that are going to make a difference for the patient,” Mayne says.
A recent study found that the prevalence of kidney disease has increased from one in every 10 adults to one in every seven or eight.
This figure is expected to rise because of higher rates of obesity, diabetes, and high BP, coupled with aging baby boomers, according to the National Kidney Foundation.
“I think it’s unquestionably been a struggle because the dialysis population has grown, but we have seen new therapies, lots of new research, and I think that we can all take pride in the fact that the mortality rates in the dialysis population are starting to come down. I think that we are making progress, and the goal is obviously to provide an opportunity for these patients to live long and live well,” Willis says.
The ESRD demonstration project is slated to end in 2009.