Fact Sheets

Kidney Care Choices (KCC) Model

This is an updated version of the fact sheet originally posted on July 10, 2019. 

Overview

The Kidney Care Choices (KCC) Model will build 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. The KCC model will 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.   The model will help delay the onset of dialysis and to incentivize kidney transplantation. The Model will include four options: the CMS Kidney Care First (KCF) Option Comprehensive Kidney Care Contracting (CKCC) Graduated Option, Comprehensive Kidney Care Contracting (the CKCC) Professional Option, and the Comprehensive Kidney Care Contracting (CKCC Global Option. The design of this model likewise draws from the Primary Care First and Direct Contracting models.

Will participation in the KCC Model be required for health care providers?
Participation is voluntary for health care providers.

What are the Model’s goals, and how will the Model achieve these goals?
The Model is designed to incentivize better management of kidney disease. A single set of kidney care providers will be responsible for a patient’s kidney care from the late stage of CKD through dialysis and post-transplant care.  A nephrology practice –the Kidney Care First practice (KCF practice) in the KCF Option– or a group of health care providers—the Kidney Contracting Entity (KCE) in the CKCC Options – will be responsible for aligning beneficiaries’ kidney care from the late stages of CKD or ESRD through dialysis, kidney transplantation, and post-transplant care.  The Model will include financial incentives to encourage KCF practices and KCEs to furnish care that meets beneficiaries’ health needs by incenting them to best guide their aligned beneficiaries through the course of their CKD stage 4 or 5 or ESRD.  In particular, KCF practices and KCEs will focus on delaying the progression of CKD to ESRD, managing the transition onto dialysis, supporting beneficiaries through the transplant process, and keeping beneficiaries healthy post-transplant.

The patient is a key component of the Model’s design. The tendency now is for patients with kidney disease to follow the most expensive treatment 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.

The Model will avoid the potential for care stinting through risk adjustment and application of quality measures, as well as monitoring activities that will ensure beneficiaries receive needed services, while retaining freedom of choice of providers. 

How will the Model build upon the CEC Model?
This Model builds on key lessons and areas for improvement recognized during the first 3 years of the current CEC Model by:

• Including Medicare beneficiaries with CKD stage 4 and 5 before they progress to ESRD, to promote later and better starts on dialysis, or to avoid dialysis entirely.
• Including beneficiaries after they receive a transplant and incorporating financial incentives to promote greater utilization of transplants.
• Empowering nephrologists to take the lead in coordinating care for beneficiaries across the care spectrum.
• Incorporating Medicare Benefit Enhancements to support improved utilization of skilled nursing facilities (SNFs), increase telehealth utilization, and increased utilization of the kidney disease education (KDE) benefit.
• Altering nephrologist payment policy in order to reduce burden and better align payments with care.

What is the timeline for implementation of the KCC Model?
Requests for applications was made public in fall, 2019. Applications are due in January 22, 2020.

The Model is expected to begin in spring, 2020 and end on December 31, 2023, with the option for one or two additional performance years at CMS’s discretion. Health care providers interested in participating will apply to participate by January 22, 2020, and if selected, begin model participation in 2020. However, financial accountability under the Model will not begin until January 1, 2021. During 2020, which CMS is referring to as the “Implementation Period,” model participants will focus on building necessary care relationships and infrastructure.
 

Who is eligible to participate in the Model?
The CMS Kidney Care First Option will be open to nephrology practices and their nephrologists only, subject to meeting certain eligibility requirements.

KCEs participating in one of the Comprehensive Kidney Care Contracting Options are required to include Nephrologists or nephrology practices and transplant providers, while dialysis facilities and other providers and suppliers are optional participants in KCEs.

How will beneficiaries be aligned to the Model?

The beneficiary alignment process will be the same for the KCF and CKCC Options. Alignment will be based on beneficiary claims. Beneficiaries who meet the following criteria will be eligible to be aligned or remain aligned to KCF practices or KCEs:

• 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 will be based on where a beneficiary receives the majority of his or her kidney care. When an aligned beneficiary receives a kidney transplant, he or she 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 he or she meets the requirements for alignment by virtue of his or her ESRD.

What will be the payment methodology for the CMS Kidney Care First Option?
In the CMS KCF Option, participating nephrologists and nephrology practices will receive quarterly capitated payments for managing care of aligned beneficiaries with CKD Stages 4 or 5 and adjusted monthly capitated payments for ESRD patients.  These payments will be 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.

What will be the payment methodology for the Comprehensive Kidney Care Contracting Options?
As in the KCF Option, KCEs will receive adjusted payments for managing beneficiaries with CKD Stages 4 and 5, and ESRD, and along with the kidney transplant bonus payment.

The CKCC Options will have three distinct accountability frameworks:

CKCC Graduated Option: This option 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 option is based on the Professional Population-Based Payment option of the 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 option is based on the Global Population-Based Payment option of the Direct Contracting Model – with risk for 100% of the total cost of care for all Parts A and B services for aligned beneficiaries. A Total Care Capitation Payment is available only in the CKCC Global Option.

The KCC Model aims to attract diverse types of health care providers operating under a common governance structure, with attention given to improved care for the affected population so as to reduce expenditures. CMS is establishing requirements for a KCE’s governance structure and beneficiary alignment, in addition to the payment, financial accountability, risk adjustment, and overlap rules.

Can KCF practices and KCEs qualify as Alternative Payment Model (APM) Entities?
KCF practices and KCEs in the CKCC Professional or Global Option will qualify as Advanced APM entities beginning in 2021, assuming that they meet the payment or patient thresholds required under the Quality Payment Program. The one-sided risk track of the CKCC Graduated option will not qualify as an Advanced APM in 2021, however, the Graduated Risk Option, Level 2 will be considered an Advanced APM.  

Will there be any Medicare benefit enhancements under the Model?
CMS is considering these Medicare benefit enhancements for the KCC Model:

• Kidney Disease Education benefit – Medicare currently covers up to six 1-hour sessions for beneficiaries with stage 4 CKD. The model would allow practitioners other than currently permitted clinicians to provide this service, which would allow the service to be furnished to beneficiaries with stage 5 CKD and certain beneficiaries with ESRD.
   
• Telehealth – Telehealth services would be allowed to be utilized for populations not classified as rural, thus providing flexibility for beneficiaries to communicate with their providers and suppliers when necessary and medically appropriate.
   
• 3-day skilled nursing facility (SNF) rule –  CMS would waive the requirement that beneficiaries complete a 3-day stay at an inpatient facility prior to being eligible for SNF admission.
   
• Post-discharge home visit – Auxiliary personnel would be able to furnish in-home services to aligned beneficiaries after a discharge from a hospital under the general, rather than direct, supervision of a physician or non-physician practitioner.
   
• Care management home visit – Home visits would also be allowed for the purposes of care management.
   
• Home Health – The “confined to his home” requirement for coverage of home health services would be waived.
   
• Home Health Services Certified by Nurse Practitioners – Would allow nurse practitioners participating in a KCF practice to certify that aligned beneficiaries are eligible to receive home health services.
   
• Concurrent Care for Beneficiaries that Elect the Medicare Hospice Benefit: Would allow KCF Practices and KCEs to waive the requirement that beneficiaries elect to forego curative care as a condition of Medicare coverage of hospice care.

How will the Model be evaluated?
An independent evaluation will be conducted for the Model. Each evaluation will assess the impact of the Model, as well as the effectiveness of implementation. The evaluation strategy reflects the need for rapid-cycle findings that will be available to CMS and model participants throughout the model test. The evaluation will employ a mixed-methods approach using quantitative and qualitative data to measure both the impact of the Model and implementation effectiveness. The impact analysis will examine the effect of the Model on key outcomes, including improved quality of care and quality of life, and decreased Medicare expenditures and utilization. The implementation component will describe and assess how participants implement the model, including barriers to and facilitators of change. Findings from both the impact analysis and the implementation assessment will be synthesized to provide insight into what worked and why, and to inform OACT certification and the HHS Secretary’s determinations on model expansion, in accordance with Sec. 1115A(c) [42 U.S.C. 1315a].

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