Fill in the form on this page to view our analysis of Kidney Care Choices. Our analysis shows the average number of CKD beneficiaries per nephrology practice per state, the average number of ESRD beneficiaries per nephrology practice per state, and the average PMPM amount per provider per state.
Differences in the KCC Payment Models
The KCF payment option differs from the CKCC payment options in a few ways. Only nephrologists and nephrology practices can participate in the KCF model, while CKCC participants are required to include transplant providers and may include dialysis facilities. Additionally, while both KCF and CKCC receive adjusted payments for beneficiaries with CKD 4, 5, and ESRD, as well as the kidney transplant bonus payment, only KCF participants receive a performance-based adjustment through quality and utilization measures as compared to all KCF practices. This performance-based adjustment applies to the monthly and quarterly capitated payments.1
As of December 2016, more than 661,000 Americans have been diagnosed with kidney failure . However, only 193,000 are living with a functioning kidney transplant. In 2013, more than 47,000 Americans died from kidney disease, higher than breast or prostate cancer.2 Additionally, in 2018 nearly 750,000 Americans and an estimated 2 million people worldwide were affected by ESRD. By implementing the KCC model CMS is trying to have nephrologists and nephrology practices manage the overall health of their beneficiaries and promote nephrologists advocating for kidney transplants over dialysis regimens.
For participants in the KCF model, nephrologists and nephrology practices will receive adjusted fixed payments on a per-patient basis, with the payments adjusted based on quality health outcomes for the beneficiaries and utilization across the practice. For the top 10% of KCF practices, the performance adjustment is up to +30%. In comparison for the bottom 50% of KCF practices that are also in the bottom 25th percentile nationally, the performance adjustment is -20%. The -20% adjustment also applies to practices that fail to pass the Quality Gateway.
Quality Gateway measures are:
- gains in patient activation scores at 12 months
- depression remission at 12 months
- high blood pressure control
Utilization measures are:
- optimal ESRD starts
- hospitalization costs
- total per capita costs
Participating practices will also receive bonus payments for aligned patients who receive a kidney transplant, with bonuses paid out annually over three years while the transplant is successful and the patient is not on dialysis. Performance-based adjustments impact the monthly and quarterly prospective payments.
Based on the KCF payment model, participating entities are prospectively paid for their CKD and ESRD beneficiary populations. For beneficiaries with ESRD, payments will be made monthly at the 2-3 visit in-center rate for each aligned patient. For beneficiaries with CKD, payments will be made on a quarterly basis for a bundle of CPT codes listed below, at ⅓ of the 2-3 visit in-center rate.3 Since both of these rates are subject to the performance adjustment, knowing the number of beneficiaries and how participating entity rates in performance will allow a practice to plan their prospective monthly and quarterly payments accurately.
Our analysis calls out the average number of beneficiaries per organization in each state. For those who are enrolled in a KCC model, CareJourney can provide analysis around county-level and provider-level attribution, as well as Medicare Part A & B costs based on the attribution.