APMS: Understanding Comprehensive ESRD Care Healthcare Management Services

Posted on  July 12, 2017

 

INTRODUCTION

The Comprehensive ESRD Care (also called the CEC) is an Accountable Care Organization (ACO) developed by the CMS Innovation Center to test innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care. It is interesting to note that this is the first ACO developed with a specific focus on a disease because it was built around identifying ways to improve the coordination and quality of care for Medicare beneficiaries living with end-stage renal disease while lowering the cost of that care.

The ACO is formed by bringing together voluntary providers and suppliers to form a legal entity that gives coordinated care to those beneficiaries with end-stage renal disease. The legal entity is referred to as the “ESRD Seamless Care Organization” or ESCO. The owners of the ESCO are required to include at least one nephrologist (or group practice) in addition to at least one dialysis facility.

WHY ADVANCED APM ENTITY NECESSARY?

In 2012, there were over 430,000 patients on various forms of dialysis. Though the growth of this population appears to be slowing, the complexity of the patients receiving this high-cost, technically complex treatment is increasing. Most of the patients have three to four comorbid conditions in addition to the ESRD. In fact, diabetes and hypertension cause ESRD in nearly two-thirds of the patients. Patients are receiving 8–10 different medications daily, and the current most common form of dialysis (three times weekly in-center hemodialysis) replaces the equivalent of 10%–14% of small solute removal compared with natural kidneys. The ability of conventional dialysis to remove the full range of toxins necessary to optimize health, including salt and water, is, frankly, inadequate.

ESRD patients continue to have high mortality and morbidity.
Mortality remains nearly 20% annually overall and nearly 40% for patients new to dialysis, with an average of nearly two hospitalizations still occurring per patient per year. Although late-stage CKD and ESRD patients comprise just over 1% of all Medicare patients, they consume nearly 10% of the overall costs of Medicare, nearing $45 billion.(1)

When the CEC Model started in October of 2015 there were 13 participating ESCOs that joined with an initial agreement period lasting for three years. When the agreement expires in 2018, they will have the option of extending the agreement for an additional two, one-year extensions based on the performance of the ESCO. There was a new solicitation for ESCOs to start January 1st of 2017 that are eligible to participate for two performance years and then will be given the option to extend their agreements for two additional, one-year extensions based on their performance. Currently, there are a total of 37 ESCOs participating in the CEC Model.

The model works by holding ESCOs accountable for clinical quality outcomes and financial outcomes measured by Medicare Part A and B spending, including all spending on dialysis services for their aligned ESRD beneficiaries. This model encourages dialysis providers to think beyond their traditional roles in care delivery and supports them as they provide patient-centered care that will address beneficiaries’ health needs, both in and outside of the dialysis clinic.

In the CEC Model, separate financial arrangements are arranged for larger and smaller dialysis organizations.

Large Dialysis Organizations (LDOs) include chains with 200 or more dialysis facilities. They will be eligible to receive shared savings payments. However, LDOs will also be liable for shared losses and will have a higher overall level of risk compared to smaller organizations.

Non-large dialysis organizations (Non-LDOs) include chains with fewer than 200 dialysis facilities, independent dialysis facilities and hospital-based dialysis facilities. These organizations have the option to participating in a one-sided track. Because they have more limited resources, they will be able to receive shared savings payments but will not be liable for payment of shared losses.


Under the CEC Model, a beneficiary is aligned to an ESCO if the beneficiary meets all the following criteria:

1. Must be enrolled in Medicare Parts A and B;
2. Must not be enrolled in the Medicare Advantage plan, cost plan, or other non-Medicare Advantage care plan at the time alignment is performed
3. Must be receiving maintenance dialysis services;
4. Must be at least 18 years of age;
5. Must reside in the United States;
6. Must not be aligned to another existing Medicare Shared Savings Program (unless otherwise determined by CMS);
7. Must not have had a kidney transplant in the last 12 months; and
8. Must have Medicare as the primary payer.

CMS will match beneficiaries to an ESCO based on dialysis utilization using a “first touch” approach— meaning that an eligible beneficiary’s first visit to a CEC Model participant dialysis facility will prospectively match that beneficiary to the dialysis facility, and by extension the ESCO, for the life of the model, unless the beneficiary loses eligibility (e.g., ceases dialysis treatment, joins Medicare Advantage, receives a functioning transplant, etc.). This type of matching is conducted on a quarterly basis.
To learn more about the Comprehensive ESRD Care Model, please visit the CMS website that is dedicated to sharing the most recent information available: Comprehensive ESRD Care Model. Additionally, you may submit questions directly to CMS using this email address: ESRD-CMMI@cms.hhs.gov.

References:

1. Nissenson AR. Improving Outcomes for ESRD Patients: Shifting the Quality Paradigm. Clinical Journal of the American Society of Nephrology : CJASN. 2014;9(2):430-434. doi:10.2215/CJN.05980613.

 
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Comments 17

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