Lawmakers concerned over scope of CMMI kidney care model

A group of 74 House lawmakers are concerned with several parts of CMMI's mandatory payment model to transition to home dialysis. (Getty/Jupiterimages)

A bipartisan group of 74 House lawmakers are demanding that the Trump administration narrow the scope of a proposed kidney care mandatory payment model and to revamp how providers are measured.

The letter sent by the lawmakers on Friday to the Center on Medicare and Medicaid Innovation (CMMI) underscores lingering lawmaker concerns over the use of mandatory demonstrations. The mandatory kidney care model, which goes into effect Jan. 1, was released earlier this year as part of an effort to get more patients to use home dialysis instead of in a clinic.

“We ask the Innovation Center to minimize the number of providers to as few needed as possible to transplant rates separately or develop as an alternative to ensure an adequate sample in a smaller segment of the country,” the letter said.

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Congress, especially Republicans, have always been wary of mandatory demonstration projects under CMMI.

The lawmakers also call for CMMI to give participants a waiver to the Stark law and antikickback statute, according to the letter led by Reps. Suzan DelBene, D-Wash., and Larry Buschon, R-Ind.

Providers have worried it is difficult for them to enter into value-based care payment arrangements for fear of running afoul of the 1989 Stark Law or antikickback law, which can penalize physicians for referring patients to facilities they have an ownership stake in.

Health and Human Services released two proposed rules earlier this month that aim to revamp Stark and create new safe harbors for the antikickback statute to shield value-based care deals.

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In July, the Trump administration rolled out five new payment models intended to overhaul kidney care.

Four of the models are voluntary and would offer payments to providers based on outcomes and performance.

One of the payment models was mandatory. It will adjust payments to providers based on their home dialysis or transplant rates, with providers getting more money for transitioning dialysis in the home. But the lawmakers worry about how the mandatory demonstration will determine the home dialysis rates. The letter says that CMMI is using a flawed metric to determine whether a patient is ready to use home dialysis.

The model proposes to use CMS risk scores that rely on ICD-10 coding to determine the patient’s propensity to use home dialysis.

However, CMS should instead use a metric that “accounts for a patient’s clinical status, including activities of daily living, as well as their ability and willingness to use home dialysis. This metric should be designed in such a way to properly align payment incentives with the best modality for the patient,” the letter said.