CMS ESRD Demonstrations

1. CMS ESRD Demonstrations 2007 CMS/Forum of ESRD Networks' Annual Meeting February 26, 2007 Heather Grimsley CMS Office of Research, Development and Information Medicare Demonstrations Program Group Division of Delivery System Demonstrations Heather.Grimsley@cms.hhs.gov 410-786-7787

2. Current ESRD Demonstration • ESRD Disease Management (DM) Demonstration

3. ESRD Disease Management Demonstration Goals • To test disease management models for beneficiaries with ESRD • Evaluate results in a managed care setting • Pilot test quality incentive payments for ESRD measures

4. Disease Management Intended To • Encourage more efficient care • Improve quality of patient care • Provide flexibility • Coordinate interventions • Educate patients

5. Disease Management (cont.) • Central role for nephrologists and disease management specialists • Management of the many co-morbid conditions associated with ESRD • Involve care managers with specialized knowledge of diet, medications, and individual needs of the patients

6. CMS Selected Three Demonstration Awardees • DaVita partnering with SCAN • Medicare Advantage Coordinated Care Plan • Service Area: Counties in Southern California • Evercare • Medicare Advantage Coordinated Care Plans • Service Area: Counties in Arizona, Georgia and Massachusetts • Fresenius partnering with American Progressive, Pennsylvania Life and Sterling Life Insurance Company • Medicare Advantage Private Fee-for-Service Plans • Service Area: Counties in Alabama, Connecticut, Massachusetts, Pennsylvania, Southern California, Tennessee, and Texas

7. Managed Care Model • All Medicare services provided • Voluntary for Medicare beneficiaries • Provides opportunity for beneficiaries with ESRD to enroll in Medicare Advantage plans • Maintain supplemental insurance (an exception for demonstration) • Additional benefits: Transportation, drugs, dental, vision, nutritional supplements

8. Managed Care Model (cont.) • All Medicare Advantage rules apply • Must meet State financial risk and licensing requirements • Medicare Advantage ESRD risk-adjusted payments • Incorporates a greater number of co-morbidities • Distinct payment for three modalities (dialysis, transplant, post-transplant) • Coordinated Care Plans offer Medicare Part D benefit

9. Payment Model • Capitation Payment Model • Risk-adjusted payments for three modalities • Risk sharing protection

10. Quality Incentive Payment • Five percent of capitation payment reserved for quality incentive payment • Clinical indicators: • Adequacy of hemodialysis • Percent of patients with spKt/V > 1.2 • Anemia management • Percent of patients with Hgb > 11 g/dL • Albumin-Corrected Serum Calcium • Percent of patients with Albumin-Corrected Serum Calcium < 10 mg/dL • Serum Phosphorus • Percent of patients with Serum Phosphorus < 6 mg/dL • Vascular access • Percent of patients with catheter in use • Percent of patients with AV Fistula in use

11. Quality Incentive Payment (cont.) • Two kinds of quality outcome objectives • Improvement over prior year performance • Improvement over a National target

12. Current Status of ESRD DM Demo • Four-year demonstration • Enrollment in MA plans began in January 2006 • Total enrollment in all ESRD DM Demo MA plans ~ 1200 beneficiaries

13. ESRD DM Demo Evaluation Evaluation Hypotheses • DM structure varies in content and approach 2. Components of DM structure are associated with improved processes of care (site-specific) 3. DM is associated with improved outcomes 4. DM is associated with improved patient satisfaction and quality of life 5. DM is well-accepted by providers • DM is associated with reduced net costs *Independent evaluation being conducted by Arbor Research Collaborative for Health

14. Pending ESRD Demonstration • ESRD Bundled Payment Demonstration (MMA §623e) – under development

15. For additional information on CMS Demonstrations and Evaluations: http://www.cms.hhs.gov/DemoProjectsEvalRpts ESRD Demonstrations