- ESRD
- ESCO
- Value Based Care
- dialysis
- ACO
- accountable care
- CKD
- transplantation
- Humans
- United States
- Medicaid
- Medicare
- Kidney Failure
- Chronic
- Quality of Health Care
- Comprehensive Health Care
The Comprehensive ESRD Care (CEC) Model is designed to identify and evaluate new ways to improve care and reduce cost for Medicare beneficiaries with ESRD (1). With 24 Fresenius Medical Care North America (FMC) sites in the ESRD Seamless Care Organizations (ESCOs), we appreciate the opportunity to discuss our approach, opportunities, and challenges. This perspective aims to highlight early learnings from the ESCO program sponsored by the Center for Medicare and Medicaid Innovation (CMMI).
The ESCO program shows three elements of value-based health care on the basis of the work by Porter and Teisberg (2), namely quality of care, service delivery (including patient experience and engagement), and cost control. We believe that the ESCO program has the opportunity to lead to a payment model with long-term sustainable results.
ESCOs in a Nutshell
An ESCO is a partnership between a nephrology practice(s) and a dialysis organization. Medicare beneficiaries with ESRD are attributed to the ESCO on the basis of “first touch.” First touch occurs when Medicare processes a claim submitted for outpatient dialysis by a dialysis clinic participating in an ESCO. The ESCO participants are responsible for the total Medicare Part A and B spending incurred by aligned beneficiaries. The CMMI establishes a historically based financial benchmark. If the cost of care for attributed beneficiaries is less than the benchmark, the ESCO participants have the opportunity to share savings with Medicare. If costs exceed the benchmark, the ESCO participants share the financial loss with Medicare. The amount of savings shared or the size of the check that the ESCO writes to Medicare is directly dependent on the ESCO’s quality score. A higher score financially advantages the ESCO, whereas lower quality scores have the opposite effect. These reconciliations of the cost and clinical quality scores occur after the performance year. All ESCO participants are exposed to more than nominal financial risk.
Today, there are 37 ESCOs participating in the Comprehensive ESRD Care Model. FMC partners with over 800 nephrology providers in 20 states and the District of Columbia to manage an ESCO population of patients clinically similar to the overall FMC patient population.
Approach to Clinical Care within an ESCO
Clinical care within an ESCO assumes broad care coordination responsibility for all clinical conditions of a patient. Patients with ESRD have high resource utilization with respect to cardiac and vascular disease, infections, behavioral health, nutrition, and endocrine care. Common sites of service include ambulatory, home, emergency department, hospital, and dialysis facility. The approach taken leverages both site of service and clinical condition competence around three themes: medical management, care navigation, and financial stewardship.
Medical management focuses on ESCO quality measures (3) and daily care. This uses algorithms to address dialysis treatment prescription, anemia management, and bone and mineral metabolism but also includes logistic aspects for vascular access, hybrid ESCO quality measures, and use of technology to drive adherence. The ESCOs are using pharmacy resources for medication oversite. The FMC Clinical Interventions Laboratory determines which clinical interventions have the greatest effect.
The FMC Care Navigation Unit (CNU) includes service coordinators, social workers, and registered nurses operating centrally and in the field. The CNU has real-time access to clinical information, leveraging algorithms and predictive models in conjunction with electronic transition of care signals and heightened communications via secure text messaging. The CNU is designed to engage with patients when they are not within the confines of a dialysis facility. One example to consider is, when the CNU receives notification electronically that an ESCO beneficiary arrives in an emergency room, they make contact with the emergency room care team, providing a clinical summary and offering assistance should the patient’s condition permit discharge.
Financial stewardship leverages actuarial and analytic methods to understand cost drivers. These include analyses at the level of the national ESCO enterprise, the local community, and individual patients with identified special needs.
The ESCO framework includes a series of waivers that permit the program to fund services beyond traditional Medicare benefits (4). One example is a transportation benefit, which permits the ESCO to fund nonemergent transportation to or from one of the participants’ venues of care.
The FMC ESCO clinical partners have created formal transition of care visits performed by nephrologists to assist with timely adjustments of clinical care parameters. A preliminary association exists between the transition of care visit and a reduction in 30-day readmission rates, which will need validation with longer experience.
Furthermore, an actuarial view of claims combined with the ability to compare multiple ESCO locations have identified outlier practices (Figure 1).
Vascular Access Clinical and Site of Service Value Plot. Arteriovenous fistula (AVF) rate minus 90-day catheter rate versus outpatient nonhospital-based site of service examines the value matrix of the experience with thrombectomy, angioplasty, and stent placement for the hemodialysis population within six original FMC ESRD Seamless Care Organizations (ESCOs; labeled A–F). The vertical axis is the ESCO-specific difference between AVF rate and 90-day catheter rate, whereas the horizontal access is the percentage of those three procedures performed in a less expensive site of service (an access center functioning as an outpatient nonhospital-based venue). The size of the bubble represents the relative census of those ESCOs. Combining clinical outcomes with claims data identifies the practices that achieve higher value in the upper right-hand quadrant of the matrix. Avg, average.
Opportunities and Challenges
What Is Working
Taking financial risk permits deployment of interventions that may not be affordable in a fee for service environment. Medicare reimbursement does not fully cover the cost of delivering the dialysis treatment. As such, additional clinical interventions outside the dialysis treatment may be financially untenable, but within the ESCO, a clinical intervention becomes affordable, because the savings partially accrue to the ESCO participants. This has led to clinical investment in policies to use antimicrobial eluting central venous catheter caps shown to reduce bloodstream infections and hospitalizations (5).
Likewise, the patients in the FMC ESCO receive benefit from additional treatment monitoring for fluid removal through intravascular volume assessment, which has required added training of clinical staff. These devices heighten the awareness and decision-making data that clinicians use to reduce volume-related hospitalization and urgent dialysis therapy (6).
What Is Not Working
One challenge to overcome in every ESCO market is the need to organize interprovider communication with respect for the timeliness of clinical decision making. Perhaps the biggest challenge with this model is that shared savings are adjudicated many months after completion of a performance year. Successful execution of the program requires upfront investment (7). Waiting for a return on this investment creates a financial challenge for participants. This flaw, which may limit scalability of the program, can be corrected by an appropriately priced prospective payment program.
Late-stage CKD care is ignored within this program. The inability to leverage ESCO waivers for Medicare beneficiaries who have not yet started dialysis creates a problem during this vulnerable and costly incident period. This issue often prevents the ESCO from using patient-specific benefits for incident patients. The unintended consequence is that, during a critical time (the first 120 days of dialysis), the ESCO cannot deploy a series of services to patients destined to become ESCO beneficiaries.
In an obvious effort to avoid disincentives for kidney transplantation, transplant expenses are carved out the ESCO. Although this approach seems prudent, it does not directly foster kidney transplantation (8). Opportunity exists to expand the CEC model to include both preemptive and prevalent patient transplantation. FMC feels that transplant care should be incorporated into the CEC model.
Finally, the CMMI has imposed a set of quality metrics that do not reflect the quality of care delivered. Fully one third of the ESCO total quality score is on the basis of a poorly validated experience of care survey. The reliability of the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems has minimal or no validation (9). For those who believe that this survey has merit for measuring patient satisfaction, we counter that we believe that the scoring within the CEC model has methodologic flaws. Furthermore, at the time of this manuscript, the majority of the hybrid measures, which make up 50% of the ESCO total quality score, do not have valid ESRD benchmarks and instead, rely on general population benchmarks. We believe that this is a serious flaw and hope that the same issues will not be replayed regarding use of the Kidney Disease Quality of Life-Performance Measure as the basis for a new ESCO measure until such time that both validity and reliability are confirmed.
Moving toward a More Mature Value-Based Care Program
The ESCO program starts to provide value-based care for people with advanced kidney disease. The program has numerous challenges that require program evolution to make the model sustainable and scalable. The ESCO as a shared savings program risks the unintended consequence of stifling innovation with its delay in adjudicating outcomes and distant financial results. Migration to a prospective payment to providers taking risk for total cost of care will foster a renewed opportunity for innovation and provide the ability to recoup care coordination investments. Furthermore, the evolution to a mature quality measurement system with adequate research and validity for kidney disease is imperative. Whether this is a model that looks like Medicare Advantage, Next Generation Accountable Care Organizations, or the Dialysis Patient Access To Integrated-care, Empowerment, Nephrologists, Treatment, and Services Demonstration Act (10), it is clear that this ESCO model is a transitional effort in value-based care. We hope that the program will improve patient attribution, payment timing, rational baseline adjustments, and scope of therapies, like kidney transplantation, to create a long-term sustainable model for care of these chronically ill people.
In summary, the ESCOs represent a major project to change the model of care for patients receiving kidney replacement therapy. This model has required substantial investment in care coordination and clinical competencies to address medical complexity and diverse venues of care for patients. FMC remains committed to the ESCO program, and together with our physician partners, we are cautiously optimistic that this demonstration will lead to better care for the patients that we serve. These early observations highlight both successes and what needs to change to improve this care model. As the program evolves, each year will add substantially to the knowledge of what really makes a positive effect on patients, the systems of care required, and the efficient use of resources.
Disclosures
F.W.M. and T.L.K. are employed by Fresenius Medical Care North America (Waltham, MA). Neither author has received any funding or external support for development of this manuscript. F.W.M. is Chair of Kidney Care Partners; is a director/board member of the following organizations: Mid Atlantic Renal Coalition, Sound Physicians, Pacific Cardiology Associates, Pacific Renal Care Foundation, and American National Bank and Trust (NASDAQ:AMNB); and sits on the Renal Standing Committee of the National Quality Forum. T.L.K. is a member of the Renal Physicians Association Board of Directors.
Acknowledgments
The statements contained in this perspectives manuscript are solely those of the authors and do not necessarily reflect the views or policies of the Center for Medicare and Medicaid Services. The authors assume responsibility for the accuracy and completeness of the information contained in this document.
The content of this article does not reflect the views or opinions of The American Society of Nephrology or the Clinical Journal of the American Society of Nephrology. Responsibility for the information and views expressed therein lies entirely with the author(s).
Footnotes
Published online ahead of print. Publication date available at www.cjasn.org.
- Copyright © 2017 by the American Society of Nephrology
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