ASN Task Force Answers Questions about Accountable Care Organizations

What were the biggest changes from the proposed rule that CMS made to the final ACO rule?

Amy Williams: CMS received extensive feedback on the initial ACO rules, including comments from ASN related to the care of individuals with chronic kidney disease (CKD), ESRD, and kidney transplants. In response to the general comments, CMS made changes that will make it easier for some organizations to form and participate in ACOs. However, the task force was dismayed that CMS did not make any substantial changes to the rule based on the ASN’s recommendations. Table 1 summarizes the most important modifications. You may access a complete list of the 33 quality measures on the ASN website.


What were the biggest nephrology-specific changes between the proposed and final rules?

Amy Williams: Although the changes to the ACO rules may allow more entities to participate in ACOs, few changes to the rule will have a direct impact on nephrologists or on individuals with nephrologic diseases. The goal of delivering patient-centered, collaborative, coordinated health care should improve the care of patients with CKD, but to accomplish this, the nephrology community must partner with the ACO primary care providers to provide appropriate guidance in the care of CKD patients and the primary prevention of renal disease.

Unfortunately, the quality metrics, although decreased in number, do not reflect priority outcomes or quality measures for patients with advanced CKD, ESRD, or recent renal transplants. Educating the ACO providers in appropriate use of the routine health maintenance and cancer screening tests in patients with advanced CKD, ESRD, and limited life expectancy will prevent unnecessary testing, possible adverse events, and unnecessary costs.

How are patients attributed to an ACO?

Amy Williams: The final process of patient assignment to an ACO has two steps: 1. Patients are preliminarily assigned to an ACO on the basis of the historical (prior 12 months) plurality of primary care G-code charges associated with an annual wellness visit or Welcome to Medicare visit attributed to the patient by a primary care provider. 2. If the patient has not had any primary care services from any primary care provider, he or she will be assigned to the specialist and the specialist’s ACO that has provided the plurality of primary care services. This “preliminary prospective assignment” allows ACOs to know which patients they are likely responsible for managing and should help them identify high-risk patients, such as those with advanced CKD and renal transplants, and facilitate early implementation of evidence-based management to improve patient outcomes and manage the cost of care. Final reconciliation of patient assignments will occur at the end of the performance period and will be based on which ACO provided the plurality of the patient’s primary services.

What are the potential positive developments for my dialysis patients if they are attributed to an ACO?

Emily Robinson: There would be pros and cons for a dialysis patient attributed to an ACO. ACOs are charged with developing processes to promote evidence-based medicine, promote beneficiary engagement, and coordinate care, all of which could help all patients, including dialysis patients. ACOs also are mandated to have systems in place to identify high-risk individuals and develop individualized care plans.

Dialysis patients specifically may benefit from improved efforts to coordinate care and efforts at medication reconciliation, one of the quality measures, because they often have medical records in many different locations and different physicians who prescribe their medications. Other quality measures, including vaccination for influenza and pneumonia as well as screening for risk of falling, may be helpful for these patients, although likely they are already being done in the dialysis units.

Amy Williams: Partnering with ACO providers to develop and implement patient education materials and best practices for treating patients with CKD, ESRD, and renal transplants could prevent adverse patient and renal outcomes from nephrotoxic medications, polypharmacy complications, and missed opportunities for renal-preserving interventions. Such coordination may lead to better preparation and appropriate referral for renal replacement therapy or conservative care, ultimately achieving better patient outcomes.

What are the potential risks or downsides for my dialysis patients if they are attributed to an ACO?

Emily Robinson: Some aspects of the ACO program may not be so positive for dialysis patients. Some of the quality measures, such as mammograms, colonoscopies, aggressive lipid management, or even aggressive blood pressure control, may not apply to dialysis patients. We may find that instead of careful consideration of the risks and benefits of these interventions in each individual patient based on specific evidence in dialysis patients, these patients may be given the interventions only to satisfy quality measures, even if they are unnecessary and potentially harmful.

If a patient is in a dialysis unit that is not associated with the primary care physician’s ACO, it is possible that the primary care physician will encourage a change of dialysis unit to one within the ACO for better control of costs and savings, even if it is not close to the patient’s home. There may be perverse incentives to hold off on access planning with CKD patients as long as possible to avoid unnecessary costs, thus increasing catheter rates among patients who are beginning dialysis.

Amy Williams: The rule states that difficult patients must be included in the ACO, and an ACO can be terminated for discriminating against these patients. However, the potential for ACOs to avoid assignment of high-risk patients is a concern. Most individuals with advanced CKD and ESRD have multiple comorbidities and require complex care. It is unclear how successful CMS will be in detecting ACOs that avoid enrolling these patients. Nephrologists will need to continue to be advocates for these patients and have a significant role in their medical management.

Emily Robinson: We hope that CMS’s efforts truly safeguard against cherry-picking of patients, and that individuals receiving dialysis, whose care is often complex, will not have a harder time finding a primary care physician willing to accept them as patients.

In the next issue the ASN ACO Task Force will address more questions, including these: Can my nephrology practice join an ACO? What will it mean for me as a nephrologist if my dialysis patients are attributed to an ACO? What other kinds of new care delivery models exist?

If you have questions about ACOs you’d like the task force to address, please email the ASN Manager of Policy and Government Affairs, Rachel Shaffer, at


[1] Amy Williams is affiliated with the Mayo Clinic in Rochester, NY, and Emily Robinson is affiliated with the Brigham and Women’s Hospital in Boston.

March 2012 (Vol. 4, Number 3)​