Fewer Patients Now Required for Groups to Apply for ESRD Seamless Care Organizations

CMS recently relented on its requirement that ESRD programs applying to form ESRD Seamless Care Organizations (ESCOs) must have at least 500 matched beneficiaries. Applicants must now have 350 matched beneficiaries, and the deadline to submit a formal application has been pushed back to July 1, 2013.

The change came after requests for greater flexibility on the threshold from many in the kidney care community—including ASN. CMS stated that the reduction was in response to stakeholder feedback and suggestions from organizations interested in new models of ESRD care.

“The lower threshold is welcome news,” said Doug Johnson, MD, vice chair of the board at Dialysis Clinic, Inc. “It will permit more providers to participate, leading to greater innovation and ultimately better care for patients with kidney disease.

CMS had originally emphasized in written communications and in conference calls with the kidney community that the 500-patient threshold was selected to ensure a statistically accurate shared savings calculation, and therefore could not be reduced.

However, some potential applicants noted that it would not be possible to achieve that minimum in a given “market”—which CMS defined as limited to just two Medicare Core-Based Statistical Areas—especially given that patients who had already been matched to a Medicare ACO or another Medicare program involving shared savings would be excluded from attribution to an ESCO.

“ASN applauds CMS and the Innovation Center for making this important change,” said ASN Public Policy Board chair Thomas H. Hostetter, MD. “The society will continue to work with other kidney community stakeholders to encourage the agency to consider what we believe are further modifications that would strengthen the program’s ability to deliver innovative, higher-quality care, support further research, and allow more nephrologists and providers to participate in the ESCO program. For instance, ASN believes it is important for CMS to describe a plan to develop dialysis-specific quality metrics in a transparent manner that allows for community input, as well as to prospectively describe the criteria it will use to determine whether an ESCO is a success or a failure.”

Also welcoming the news were stakeholders who are not eligible to apply as participants, but who are invested in the success of the program given its potential to improve care for patients on dialysis.

“The American Nephrology Nurses Association (ANNA) was delighted that CMS reconsidered the minimum number of ESRD participants in an ESRD Seamless Care Organization (ESCO) to allow smaller providers to participate in these innovative programs,” said ANNA immediate past president Glenda Payne. “Having broader representation in this project increases the potential for innovation. ANNA believes that registered nurses and Advanced Practice Registered Nurses (APRN) will play critical roles in every ESCO, as nurses are traditionally the primary coordinators of care, and APRNs will provide close oversight of patients, working with nephrologists to improve the care patients receive and taking action to prevent complications and reduce the need for hospitalizations.”

“The National Kidney Foundation is hopeful that reducing the minimum beneficiary requirement will encourage a greater range of providers to develop innovative care coordination models that target the specific health care needs of the patients in their community,” said NKF President Beth Piraino, MD. “Having a diversity of models will help inform future strategies for broadly delivering higher quality care that serves patients’ health, lifestyle, and community support needs.”

CMS said in its announcement of the lower threshold that participants’ savings rates will have to change to maintain the same level of statistical accuracy in calculating shared savings or losses. Owing to the lower threshold, the minimum savings rate in the payment track for non-Large Dialysis Organizations (LDO) will increase from 4 percent to 4.75 percent for those non-LDO participants that have between 350 to 499 matched beneficiaries in performance years 1 and 2.