Seamless Care in ESRD: Early Results from the Comprehensive ESRD Care Model

By Sri Lekha Tummalapalli, MD, MBA

ESRD Seamless Care Organizations (ESCOs) may be the most flexible and innovative care model in nephrology over the past several decades.  Tom Duvall, co-lead for the Comprehensive ESRD Care (CEC) Model at the Center for Medicare and Medicaid Innovation (CMMI), provided a national overview of ESCOs since their start in 2015.  Dr. Dylan Steer, CEO of Balboa Nephrology Medical Group, then shared his ground-level experience with running an ESCO.

Comprehensive Care for ESRD Patients

About two-thirds of Medicare spending on dialysis patients is for non-ESRD care.  The ESCO model puts dialysis clinics and nephrologists at the center of the patient’s care, with the goal to decrease costs and improve quality.  ESCOs are held responsible for clinical outcomes and financial risk.  The model started 9/1/2015 with 13 ESCOs, and 24 centers were added on 1/1/17. The current 37 ESCOs consist of 33 affiliated with large dialysis organizations and 4 independent facilities.  One dialysis treatment is enough to enroll a patient in an ESCO, but patients remain attributed to the ESCO only if they receive >50% of treatments in that region. Reporting requirements through the Merit-based Incentive Program System are eliminated.

Promising Early ESCO Results

Tom Duvall explained that historical expenditures are adjusted forward to calculate risk-adjusted observed/expected spending.  Shared savings are adjusted based on quality performance. The model has not been rebased, as rebasing the model would diminish shared savings over time.

Early ESCO results have been extremely promising. In performance year 1 of the model, the 13 ESCOs had $75 million in cost savings, a reduction of >5% of spending, primarily in hospital spending and post-acute care.  Patients were 6% less likely to be hospitalized and 8% less likely to have a catheter. There was no increase in use of home dialysis. Results from performance year 2 are forthcoming.

Patients and Nephrologists at the Center of ESRD Care

Ultimately, the goal of ESCOs is to set the right incentives so that ESCO leaders are empowered to seek the solutions that best serve their patients. Dr. Dylan Steer stressed the role of nephrologists as the primary physicians for ESRD patients. Instead of a mindset of “dialysis care,” he urged a Principal Care Physician mindset of “I’m the patient’s physician.  What other things can I do to give my patients the care that they need and want?”

In his role leading an ESCO, he designed novel care pathways that differed for short versus long hospital stays for his patients. They set internal quality metrics via a dashboard across whole practice. Care coordinators focusing on vulnerable transition points such as hospital discharges. They adopted patient-centered solutions such as a mentorship group amongst patients. While dialysis care spending increased, their ESCO successfully shifted care from hospital out to dialysis center through these efforts.

The nephrology community is enthusiastic to see what the future for the ESCO model holds.  Plans for expansion of the model will be determined after 4 years of the initial ESCOs have ended in 9/2019.  Creating flexibility and accountability has allowed many ESCOs to reduce spending while simultaneously achieving better care.

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Sri Lekha Tummalapalli, MD, MBA
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ESRD Seamless Care Organizations (ESCOs) may be the most flexible and innovative care model in nephrology over the past several decades.  Tom Duvall, co-lead for the Comprehensive ESRD Care (CEC) Model at the Center for Medicare and Medicaid Innovation (CMMI), provided a national overview of ESCOs since their start in 2015.  Dr. Dylan Steer, CEO of Balboa Nephrology Medical Group, then shared his ground-level experience with running an ESCO.

Comprehensive Care for ESRD Patients

About two-thirds of Medicare spending on dialysis patients is for non-ESRD care.  The ESCO model puts dialysis clinics and nephrologists at the center of the patient’s care, with the goal to decrease costs and improve quality.  ESCOs are held responsible for clinical outcomes and financial risk.  The model started 9/1/2015 with 13 ESCOs, and 24 centers were added on 1/1/17. The current 37 ESCOs consist of 33 affiliated with large dialysis organizations and 4 independent facilities.  One dialysis treatment is enough to enroll a patient in an ESCO, but patients remain attributed to the ESCO only if they receive >50% of treatments in that region. Reporting requirements through the Merit-based Incentive Program System are eliminated.

Promising Early ESCO Results

Tom Duvall explained that historical expenditures are adjusted forward to calculate risk-adjusted observed/expected spending.  Shared savings are adjusted based on quality performance. The model has not been rebased, as rebasing the model would diminish shared savings over time.

Early ESCO results have been extremely promising. In performance year 1 of the model, the 13 ESCOs had $75 million in cost savings, a reduction of >5% of spending, primarily in hospital spending and post-acute care.  Patients were 6% less likely to be hospitalized and 8% less likely to have a catheter. There was no increase in use of home dialysis. Results from performance year 2 are forthcoming.

Patients and Nephrologists at the Center of ESRD Care

Ultimately, the goal of ESCOs is to set the right incentives so that ESCO leaders are empowered to seek the solutions that best serve their patients. Dr. Dylan Steer stressed the role of nephrologists as the primary physicians for ESRD patients. Instead of a mindset of “dialysis care,” he urged a Principal Care Physician mindset of “I’m the patient’s physician.  What other things can I do to give my patients the care that they need and want?”

In his role leading an ESCO, he designed novel care pathways that differed for short versus long hospital stays for his patients. They set internal quality metrics via a dashboard across whole practice. Care coordinators focusing on vulnerable transition points such as hospital discharges. They adopted patient-centered solutions such as a mentorship group amongst patients. While dialysis care spending increased, their ESCO successfully shifted care from hospital out to dialysis center through these efforts.

The nephrology community is enthusiastic to see what the future for the ESCO model holds.  Plans for expansion of the model will be determined after 4 years of the initial ESCOs have ended in 9/2019.  Creating flexibility and accountability has allowed many ESCOs to reduce spending while simultaneously achieving better care.

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Date:
Monday, October 29, 2018