InnCMS ANNOUNCES FOR DEMONSTRATION SITES FOR BENEFICIARIES WITH END STAGE RENAL DISEASE
The Centers for Medicare and Medicaid Services (CMS) today announced that it has selected two organizations to participate in a new demonstration that will increase the opportunity for Medicare beneficiaries with end stage renal disease (ESRD) to join managed care plans.
This demonstration has been designed to test the effectiveness of disease management models to increase quality of care for ESRD patients while ensuring that this care is provided more effectively and efficiently.
“Medicare is offering new, innovative health care options to chronically ill beneficiaries with ESRD,” said CMS Administrator Mark B. McClellan, M.D., Ph.D. “This demonstration can help us determine the benefits of disease management and care coordination for this population.”
Medicare Advantage organizations and dialysis providers are partnering to offer health plans to beneficiaries with ESRD. The health plans will provide all Medicare covered benefits with an emphasis on disease management and care coordination.
In the first year of the demonstration, the Medicare Advantage plans will be offered in four states.
- DaVita, a dialysis provider, is partnering with SCAN Health Plan to offer a Medicare Advantage Special Needs plan in parts of San Bernadino and Riverside counties in California.
- Fresenius Medical Care North America, a dialysis provider, through it’s wholly owned subsidiary Fresenius Medical Care Health Plan is partnering with Sterling Life Insurance Company in Philadelphia and Pittsburgh , Pennsylvania and Dallas, Houston and San Antonio , Texas and partnering with American Progressive Life and Health Insurance Company in Boston and Springfield , Massachusetts to offer Medicare Advantage Private Fee-for-Service plans.
Beneficiaries will be able to enroll in these new plans beginning November 15, the Medicare health plan open enrollment period, with coverage beginning January 1, 2006.
An important aspect of this demonstration is the emphasis on quality improvement and pay-for-performance. CMS will reserve five percent of the capitation payment rates for incentive payments related to quality improvement. Participating organizations will receive payment for improvement on past performance and performing above the National averages for quality measures related to dialysis.
Fresenius Medical Care North America (FMCNA) will conduct a "Disease
Management Development Study of an Expanded Bundle" concurrent with the
capitated demonstration. In Phase I of this study FMCNA will
retrospectively apply a dialysis bundle payment reimbursement structure to
the services/provider claims. FMCNA will compare the economic results of
the bundle to the full capitation payment and the risk adjusted baseline
cost. In Phase II of this study FMCNA will utilize a separate provider
based disease management model and will compare clinical and utilization
parameters against patients enrolled in the original full capitation
demonstration program and a control group of non-enrolled beneficiaries.
Participating organizations were selected through a competitive process. Organizations were selected based on technical review panel findings, organizational structure and operational feasibility.
This demonstration is the latest in an ongoing series of disease management and pay-for-performance demonstrations:
- DaVita’s wholly owned subsidiary, RMS Disease Management, LLC, was reviously selected by CMS for the Care Management for High Cost Beneficiaries (CMHCB) Demonstration. This demonstration will test the ability to coordinate care for high-cost/high-risk beneficiaries who have chronic kidney disease by providing support to manage their conditions and to prevent further development of their illnesses which may lead to further complications and End Stage Renal Disease (ESRD). RMS will provide services to selected Medicare beneficiaries in Nassau, Queens, and Suffolk counties in New York.
- The Physician Group Practice Demonstration is designed to encourage physician groups to coordinate their care for chronically ill beneficiaries, give incentives to groups that provide efficient patient services, and promote active use of utilization and clinical data to improve efficiency and patient outcomes.
- The Medicare BIPA Disease Management Demonstration tests whether disease management programs, along with outpatient drug coverage, provided to Medicare fee-for-service beneficiaries who suffer from heart problems and complex diabetes can result in better patient outcomes.
- The Premier Hospital Quality Incentive Demonstration recognizes and provides financial rewards to hospitals that demonstrate high quality performance in treating five clinical conditions.
- The Medicare Coordinated Care Demonstration tests whether coordinated care can improve medical treatment plans, reduce avoidable admissions and promote other desirable outcomes among Medicare beneficiaries with chronic diseases.
Further information on the ESRD Disease Management Demonstration is available at http://www.cms.hhs.gov/researchers/demos/esrd_demo.asp .
Additional information on other Medicare demonstrations is available at http://www.cms.hhs.gov/researchers/demos/.