Last Call for ESRD Seamless Care Organizations Issued

Mark Lukaszewski
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The Centers for Medicare & Medicaid Services (CMS) has announced a new—and likely its last—request for applications (RFA) for the ESRD Seamless Care Organizations (ESCOs).

If the RFA does not yield the expected 10 to 15 unique ESCO participants, CMS said it will consider scrapping the program. CMS emphasized that it reserves the right to terminate any model if it is not achieving the goals of the initiative. In its announcement, CMS stated that while it is “committed to improving care for beneficiaries with ESRD, the Agency reserves the right to decide not to move forward with the [Comprehensive ESRD Care] Model for any reason, as is true for all models.”

Yet it is not all bad news for the future of the ESCO program. CMS has made vast improvements in this latest RFA, including changes to address rebasing concerns in years 4 and 5, and releasing proposed quality measures that would assess program participants’ performance.

Searching for cost savings

To meet the ever-growing need for cost savings in the Medicare part D system, CMS developed the first-ever disease-specific accountable care organization (ACO) for dialysis providers. Designed to reduce duplicative services and expenditures, the ACO would consolidate all aspects of care for patients with end stage renal disease (ESRD).

According to CMS, the initiative will identify, test, and evaluate new ways to optimize the quality of care for Medicare beneficiaries with ESRD. To do so, CMS will partner with health care providers and suppliers to test the effectiveness of a new payment- and service-delivery model with the goal of providing beneficiaries patient-centered, high-quality care resulting in improved outcomes and overall Medicare savings.

Positive changes to the ESCO application process

ASN believes that CMS’s revised RFA was a step in the right direction and may entice organizations to participate in the program. The new RFA eliminates its original concept of reimbursing the program in years 4 and 5. This would have effectively penalized the highest performing ESCOs. This is a major change that will make the program more attractive to participants who are investing in costly resources and activities that will deliver better, higher-value care—the goal of the ESCO program.

Second, CMS said that allowing aggregation of beneficiary numbers and financial benchmarking information among smaller, non–large dialysis organization (LDO) providers is a positive change that might induce smaller providers to participate.

Finally, removing the requirement that nephrologists must be independent entities will likely make it possible for more nephrologists to consider becoming an ESCO-participant owner. Consequently, a nephrologist could be employed full or part time by another entity and still take an ownership share in the ESCO.

Outstanding challenges

Although CMS has made significant changes to attract greater participation, some are still concerned these changes may not be enough. Challenges to the program still remain. For instance, no end points have been established regarding what success will look like or how ESCOs will be judged as a success or a failure. The program is fundamentally an experiment, but in the scientific world one would never start a trial without first determining the end points being aimed for and what would define success.

Another major concern is how the ESCO program will incentivize kidney transplantation, one of the program’s stated goals. Financial incentives in the current RFA do not seem to be aligned to promote transplantation, and CMS has not articulated any strategies to rectify this.

The proposed technical expert panel (TEP) measure recommendations put forth were either not tested for dialysis patients or were recycled from general ACOs, not accounting for protocols that ESCOs would already be following. By making the proposed measures nonspecific to an ESCO population, CMS is increasing the administrative burden while not increasing patient quality. If the care organization is targeting a very specific population, the metrics should be as specific as possible to fit the unique needs of that population in order to optimize patient quality of life, satisfaction, and outcomes.

In addition, CMS does not take into account that ESCOs are incentivized to reduce expensive hospital-based care. This means that metrics designed to reduce hospitalizations and other expensive care may, in fact, be redundant administrative demands with no tangible effect on clinical outcomes. Finally, it is unclear how the metrics will interface with existing metrics in the Quality Incentive Program (QIP) as well as interpretative guidance in the Conditions for Coverage. Although it is stated that QIP metrics will be applied to the ESCO model, when QIP measures overlap with or supersede an ESCO measure, how will this be addressed? ASN, along with others from the kidney care community, has submitted comments to CMS regarding the proposed measures and will continue to work with CMS to produces patient-centered care for the ESCO program.

ASN remains hopeful that CMS can work within the community to finalize measures that fit the ESCO patient populations, and maintains that, if implemented appropriately, they could save costs while providing the highest care for patients.

The deadlines to apply for the ESCO program are June 23, 2014, for LDOs and September 14, 2014, for non-LDOs. CMS stated that the letters of intent will be used only for planning purposes and will not be binding. Applicants may access the application portal at