NN&I - April 2010
8 Nephrology News & Issues April 2010www.nephronline.com Mr. Neumann has been editor of Nephrology News & Issues since 1989.FIRST WORDBy Mark E. Neumannpatient's care with a team of subspe-cialists. If the model works, it can replace the fragmented, inefficient system we today hoist onto individu-als with chronic kidney disease. How do ACOs work?A good portion of patients who arrive at their first dialysis treatment are older than 65 and suffer from a multitude of comorbidities: diabetes, hypertension, cardiovascular disease, and anemia. Many of those condi-tions are the result of poor preventive carebrought on by insurers who don't want to pay for it, doctors who don't know how to manage it, and patients who don't want to believe it. But if you could wrap all these health conditions under the mana -gerial thumb of one caregiver with access to a team of specialists, you could bring all these problems under control. ACOs may also bring together the Holy Grail of health care spend- ing: Medicare's Part A and B. Part A spending goes to hospital care; Part B spending covers outpatient services, physician payment, and drugs. Part Da newcomeralso covers cer -tain drugs for the elderly. If you have a unified patient care management approach, your payment system should be, too. Thus, Part A admin-istrators no longer keep the rewards delivered by Part B caregivers; every-one shares in the improved clinical outcomes of a comprehensive care model. And patients have a better sense of who's in charge of their care.ACOs and Medicare Certainly, ACOs are favored by the government because they have the potential to save money (lan -guage to develop ACOs is in both the House and Senate health care reform legislation as of this writing). Health care spending in the United States is now 16% of gross domestic product, and heading to 20%the highest of any developed country.But in his talk, Straube also made it clear that Medicare and its inves -torsnamely the publicwant to see development of a better care model for all beneficiaries. In ESRD, for example, an ACO could help direct medical needs for patients in Stage 1 and 2 CKDa timeframe that gets little attention but offers the oppor -tunity to slow the progression of kid- ney disease. When dialysis appears inevitable, the ACO model might also go a long way to improving vascular access management. Getting the best possible access today can be a shot in the dark, dependent on pre-dialysis care, the moxie of your nephrologist to insist on the best access available, and the skill set and motivation of the local surgeon. It is one aspect of dial-ysis that begs for a unified approach. Perhaps an ACO can help.There are still many details to work out before ACOs become a reality, namely if nephrologists even want to take on that role of primary caregiver. But a global approach to complex conditions like renal dis -ease makes sense. How ACOs blend with CMS strategySometimes, it pays to wait. If you were at the well-attended Renal Physicians Association meet -ing last month in Baltimore, pro- gram chair Franklin Maddux, MD, made sure there were topics of inter -est for everyone: developing a CKD clinic, merging physician practices, quality measuring and reporting, and updates on current physician-directed legislation and policy. It was two and a half days packed with opportunities for learning. But the last half day of the pro-gram was perhaps the best if you were interested in the future of dialy -sis care. Topics included develop -ment of accountable care organiza -tions, the pending bundled payment system for dialysis services, and an in-depth presentation by nephrol -ogist and Centers for Medicare & Medicaid Services chief medical offi -cer Barry Straube about future direc- tions for his agency. After listening to Maddux's talk on ACOs and Straube's discussion about reforming Medicare and Medicaid's health care delivery systems, it became clear that the ACO model of care and CMS were on a similar path: ACOs fit in with CMS's interest in a care model for its beneficiaries led by a primary care giversomeone who manages that FirstWord_NNI0410_4.indd 8 3/19/10 11:40:37 AM
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