Thursday, June 2, 2022

The CMMI Kidney Care Demo: Physician Transplant Bonus

One of the high-priority initiatives of the Trump administration was to improve incentives and processes for end stage renal disease and to improve solid organ transplant incentives and outcomes for both kidney patients and other transplant patients.   Solid organ info here, solid organ fact sheet here, my blog on the programs in 2019, here, and HHS 38 page white paper on the programs here.  For renal patients, incentives programs were strengthened to move patients from clinic dialysis (where most sit) to either home dialysis or better, to transplant.

While doing some client research on CMMI, I ran across the March 2022 RFP for applications to the Kidney Care Choice (KCC) program - notice here.  The 90 page application for the 2023 program year is here at CMS (RFP response due March 25), and I placed an RFP cloud copy here.  The CMMI KCC home page is here, a press fact sheet from December 2019 here.

Much has been written on the theme that most physician incentives in quality programs are too small to move the needle and make a difference (e.g. Delbanco et al., 2018, here.)   

Without looking for it, I stumbled across the bonuses for kidney transplant buried down on page 24 of the 90 page application.  They run up to $15,000 per patient.  That's an incentive indeed.  I don't think this has been widely remarked on.  (Find an excellent 2020 article by Lentine in Kidney360, discussing pro's and con's of recent chagnes, here.)  

I include some clippings from the 90 page application below. Click to enlarge.


For a 2016 article on how CMS paid for dialysis forever but only limited payment for kidney transplant rejection drugs, here.  This transplant drug benefit was extended in December 2020 (here, here).  ("The US Senate passed the Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act as part of a broad year-end legislative package, extending Medicare coverage of life saving immunosuppressive medications for the life of the kidney transplant. An estimated 375 adult kidney transplant recipients lose their transplant every year due to a lack of coverage of immunosuppressive medications after the prior 36-month Medicare coverage period.") (See S 3353.)  (See also Gill, 2021 here).

I wondered if KCC is an incentive to delay transplants for patients in, say, December 2022, if the program starts at a center on January 1, 2023.  E.g. would one want to shift four transplants from December 2022 to January 2023 and trigger a $60,000 bonus thereby.


For the Fact Sheet on the CY2023 ESRD proposed rule, here, June 21, 2022.

For the proposed rule CY2023 ESRD, here.

For the December 2021 public comment solicitation on ESRD and transplant equity, here.