Innovation Center Announces Long-Awaited ESRD Care Model

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The government agency charged with developing new health care payment and service delivery models—CMS and its Center for Medicare and Medicaid Innovation (CMMI)—recently announced the Comprehensive ESRD Care Initiative.

The announcement marks the end of months of speculation about when—and whether—the Innovation Center would announce a coordinated care model for kidney care. ASN, along with many other stakeholders in the kidney community, advocated in support of such a model. However, as of press time, numerous details about the Innovation Center’s vision for the program remained unclear to many in the kidney community.

CMS began accepting letters of intent for the Comprehensive ESRD Care Initiative in early February. The Innovation Center states that it anticipates that 10 to 15 so-called ESRD Seamless Care Organizations (ESCOs) will participate in the model. The first performance period for the model will begin in the fourth quarter of 2013, and interested participants must submit a letter of intent by March 15 and apply by May 1.

Yet it is unclear how many dialysis organizations, nephrology providers, and other health professionals will ultimately participate—and whether CMS will consider altering specifics of the program.

The Comprehensive ESRD Care Initiative is the first chronic disease-specific shared savings model that the Innovation Center has launched. While other fields of medicine—including oncology—have been similarly interested in a model that may improve care and reduce costs for patients with complex, high-cost conditions, nephrology is the first to pioneer the disease-specific coordinated care model. Ideally, early experiences in ESCOs could yield valuable lessons for other areas of medicine as they consider their own disease-specific shared savings models.

The Comprehensive ESRD Care model does not reflect all of ASN’s goals for the program—including that patients with late-stage chronic kidney disease be included in the model. But several key goals were addressed, including highlighting the importance of a nephrologist-led interdisciplinary care team.

The stated purpose of the model is to “improve outcomes for Medicare beneficiaries with ESRD and reduce total per capita expenditures by creating financial incentives for dialysis facilities, nephrologists, and other Medicare providers of services and suppliers to collaboratively and comprehensively address the extensive needs of the complex ESRD beneficiary population.” In other words, ESCOs are responsible for all Medicare Part A and B care, with the exception of costs that might be incurred related to kidney transplant surgery.

At a minimum, ESCOs must include a dialysis provider, a nephrologist, and “at least one other Medicare enrolled provider or supplier.” Beyond that, CMS anticipates that an extended interdisciplinary team would support the care of ESRD patients, including general internists, endocrinologists, cardiologists, vascular surgeons, podiatrists, psychiatrists, nurse practitioners, physician assistants, registered nurses or licensed practical nurses, and health educators.

The Innovation Center’s Request for Applications (RFA) points out that the care needs of beneficiaries with ESRD are typically complex owing to multiple co-morbidities and polypharmacy, requiring care coordination services that many of them do not routinely receive today. It specifies that ESCOs must emphasize coordination across a range of providers and settings, observing that “this may be best achieved through the establishment of an interdisciplinary care team—led by a nephrologist.”

The comprehensive care model includes three possible payment arrangements. One of these arrangements applies to ESCOs that contain one or more large dialysis organization (LDO) participant-owners, and the other two are options for ESCOs that do not have any LDO participant owners. The extent to which the ESCOs may share in savings or losses will vary according to which payment arrangement they select. Like many other payment and service delivery models, the Innovation Center is testing—including Accountable Care Organizations (ACOs)—ESCO quality measure reporting will be a key mechanism CMS and the Innovation Center will use to asses patient outcomes, care coordination, and clinical improvements. CMS will factor ESCOs’ quality scores into the calculation of shared savings and losses—and ESCOs will be required to meet a minimum threshold score to be eligible to receive shared savings.

However, the RFA did not include specific quality measures that ESCOs will be judged upon, nor a scoring methodology. CMS stated that it will “provide ESCO applicants/selected participants with more information regarding quality scoring before they have to commit” to participating in the model. CMS has stated that it will select quality measures “in consultation with national ESRD experts, including patient advocates and nephrologists,” and suggested that the priorities outlined in Table 1 will influence its decision-making.

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ASN leaders said they look forward to collaborating with other health professional and patient organizations to recommend measures for ESCOs that are based on strong scientific evidence, would have a meaningful impact on care from a patient perspective, and do not create an undue reporting burden for dialysis facilities. The society also looks forward to working with these groups to recommend other considerations for optimal implementation of ESCOs.

Another aspect of the RFA that has raised some concern in the community is the minimum 500 patient threshold for an ESCO. Given CMS’ stipulation that the area that an ESCO defines may be no larger than two contiguous Medicare core-based statistical areas, it may be hard for some smaller—and even potentially some larger—dialysis organizations to meet that threshold. Related to the threshold concern is the fact that beneficiaries who have already been matched to a Medicare ACO or another Medicare program/demonstration/model involving shared savings at the date of initial matching for the ESCO program are ineligible for the ESCO. In markets with one large ACO or multiple ACOs, the possibility that patients have already matched and are ineligible is a real possibility.

As more clarity around the RFA and more news of the community’s reaction unfolds, look for additional coverage and analysis of ESCOs in ASN Kidney News.

March 2013 (Vol. 5, Number 3)