The points that Allen Nissenson makes are summarized as follows:
1. Health care reform, if it survives constitutional challenge in the US Supreme Court, will likely change the
delivery of kidney disease care by:
- Increasing health care access to 22 million Americans by 2014
- Adjusting reimbursement rates downward, except potentially in primary care
- Creating alternate pay structures, such as ACOs, to constrain costs.
Nissenson argues that a renal focused ACO is a logical next step in the delivery of care to kidney patients because he writes: "Nephrologists already treat patients in ways that fit with the ACO
model. Nephrologists treat kidney disease as well as multiple comorbid
conditions in patients with ESRD; thus, many already serve as principal
care physicians. The patient-centered medical home, which defines and
uses the concept of principal care physicians and the ability of
specialty practices to serve as medical homes, is suggestive of a
dialysis facility. The kidney community's experience with “bundled
payments” under the prospective payment system and the ESRD
demonstration project has spurred innovations in processes of care.
Preventive care in the form of immunizations, noncatheter vascular
access, diabetic care, home weight monitoring, and oral nutritional
supplements are key components currently being tested. Finally,
nephrologists regularly work with varied members of the care team (eg,
dietitians, social workers, nurses, and patient care technicians) and
other physicians (eg, vascular surgeons, endocrinologists,
cardiologists, and general practitioners) to coordinate the care of
dialysis patients."
Nissenson and colleagues make the point that there are specific criteria for who can form an ACO. Specificaly, he writes: "Only the following providers are eligible to form ACOs: ACO
professionals (eg, physicians, physician assistants, nurse
practitioners, and clinical nurse specialists) in group practices,
networks of individual practices of ACO professionals, partnerships or
joint venture arrangements between hospitals and ACO professionals,
hospitals employing ACO professionals, critical access hospitals that
bill under method II, and recognized providers or suppliers.
Nonphysician nonhospital providers (eg, dialysis providers) are not
eligible to form an ACO." Although Nissenson doesn't explicitly advocate for dialysis providers to be permitted to form ACOs, he implies this in his article. Since the article originates from DaVita, one obviously wonders if renal ACOs would benefit for-profit providers like DaVita.
The one statement that I don't agree with in his article is this: "The proposed ESRD Quality Incentive Program measurements will require
dialysis organizations and nephrologist practices to continue to
implement, test, and refine care processes focused on integrated care." I am not sure how Allen Nissenson reaches this conclusion - the value of QIPs has been debated elsewhere.
