ESRD Seamless Care Organizations: Where Do We Go from Here?

The deadline for nephrologists and dialysis facilities to apply to become an ESRD Seamless Care Organization (ESCO)—the first-ever disease-specific Medicare Shared Savings Program—has come and gone. As of press time, it appears that the Centers for Medicare and Medicaid Services (CMS) received fewer applications than the agency and the community had once hoped.

CMS had originally stated that it expected between 10 and 15 unique ESCOs to participate, with representation from all dialysis provider organizations/facility types and geographic areas—and that it would consider making more than 15 awards “if a compelling reason exists to do so.” No official count of the number of applications has yet been announced, but a number of complications—including a CMS proposal to reduce the ESRD Prospective Payment System base rate by 9.4% and outstanding questions such as what quality measures will be used to evaluate the program—suggest a lower participation rate.

It is still unclear how financially viable the shared savings model would be, especially in light of the proposed cuts to the ESRD payment system.

Since CMS announced the Comprehensive ESRD Care Initiative in February 2013, there were several changes along the way. In addition to pushing back deadlines, the agency also shared information it previously indicated could not be made public regarding how many dialysis patients are currently attributed to traditional Accountable Care Organizations. (CMS’ ESCO Request for Proposal specifies that patients who are already being attributed to traditional Accountable Care Organizations are not eligible for attribution to an ESCO.) Another key change was the lifting of the requirement that nephrologists and dialysis facilities must apply jointly with a “third Medicare eligible provider,” thereby making it easier to form an ESCO.

Despite these changes, many uncertainties with the model remain. Table 1 summarizes ASN’s top concerns and recommendations for improvement.


At press time, ASN was set to meet with CMS and Center for Medicare and Medicaid Innovation leaders to talk about the future of the ESCO program. Other patient and health professional organizations expected to attend included the American Association of Kidney Patients, the American Kidney Fund, the American Nephrology Nurses Association, the American Society of Pediatric Nephrology, Dialysis Patient Citizens, and the Renal Support Network.