Table 5.

Similarities and differences between the ESRD PPS and ACOs

Congressional mandateImprove quality and decrease costImprove quality and decrease cost
Target of mandateOutpatient dialysis careFull continuum of care
Payment mechanismBundled payment for ESRD services except provider fees; not fully capitated systemEither fee-for-service or bundled payment; all costs, including hospital and provider costs incorporated; not capitated per se but ACOs penalized for exceeding expected benchmark costs
Performance measuresQIP, which penalizes up to 2% of paymentPay for performance, with pay dependent on achieving both cost savings and performance on 33 metrics, awarding up to 50%–60% of the difference between expected benchmarks and actual costs to the ACO not to exceed 10%–15% of the organization’s Part A and Part B expenditure target; if the actual costs exceed expected costs, there will be no pay for performance
Financial incentivesDialysis provider retains unused funds from capitated paymentShared savings from first dollar and meeting performance metrics
Financial riskOutlier payments funded by 1% initial “penalty” reallocated for most expensive patientsVaries based on ACO election to shared saving versus shared savings/losses model
MonitoringCROWNWebNo fully outlined mechanism beyond ACO self-monitoring
DOPPS Practice Monitor
Patient choiceFree to select dialysis facility; facilities do have some latitude to not accept patientsFree to seek care from any CMS provider, including opting out of ACO assignment
Primary “driver” of careDialysis provider (facility)Primary care provider (organization)
  • PPS, Prospective Payment System; ACO, accountable care organization; QIP, Quality Incentive Program; CROWNWeb, Consolidated Renal Operations in a Web-Enabled Network; DOPPS, Dialysis Outcomes and Practice Patterns Study.