ESCO management: Looking for a level playing field in integrated care

The Centers for Medicare & Medicaid Services’ Innovation Center re-opened the application process earlier this summer for the Comprehensive ESRD Care (CEC) demonstration. The move was an effort to encourage smaller dialysis providers to join the five-year project aimed at testing the effectiveness of integrated care for end-stage renal disease. The deadline for applications was July 15; the agency will announce any new accepted participants next month, with a January 2017 launch.

They would join 13 ESRD Seamless Care Organizations (ESCOs) already in place and underway in the demonstration since last October.

In the care model, dialysis clinics, nephrologists and other providers create ESCOs with other partners to coordinate care for matched beneficiaries. ESCOs are accountable for clinical quality outcomes and financial outcomes measured by Medicare Part A and B spending, including all spending on dialysis services for their patients.

The challenge for small providers was bringing together enough patients (350 minimum) to meet the demonstration’s requirement (CMS said it needed at least that number to do proper data analysis), and facing the risk of losing money on patients who cost more than the baseline established by CMS at the start of the demonstration.

In the revised, round 2 application, smaller providers now have the option to accept that risk––and potentially earn more savings from the more efficient care they deliver––or decline that risk and accept a lower return. CMS believes offering that option will encourage smaller providers to join. “Smaller providers have the option of participating in a one-sided track where they will be able to receive shared savings payments, but will not be liable for payment of shared losses; or, participating in a track with higher risk and the potential for shared losses,” CMS wrote on the CEC website.

Key resources on the CEC

Replays of the CMS-directed webinars focused on applying for the CED demo are available.

Comprehensive End-Stage Renal Disease Care (CEC) Model - Application Kickoff

Comprehensive End-Stage Renal Disease Care (CEC) Model - The ESCO Experience

Comprehensive End-Stage Renal Disease Care (CEC) Model - RFA and Application

Comprehensive End-Stage Renal Disease Care (CEC) Model - Finance and Quality Methodologies

Comprehensive End-Stage Renal Disease Care (CEC) Model - Clinical Providers and the CEC Model

The webinars are available at https://innovation.cms.gov/initiatives/comprehensive-ESRD-care/archived-materials.html

NN&I asked Barry Smith, MD, PhD, CEO for Rogosin Institute, the only small dialysis organization in the current CEC demonstration, how the company had succeeded to date and thoughts on the value of having other small providers in the mix. -by Mark Neumann

NN&I: Give us the details of your ESCO –– how many patients are in your program, facilities, and other partners.

Barry Smith, MD, PhD: Our ESCO is called the Rogosin Kidney Care Alliance and includes approximately 400 Medicare ESRD patients from the New York City metro area. Two Rogosin facilities are participating in the demonstration, and our partners include Calvary Hospital and its Palliative Care program and the Frumkin Medical Practice, which has two nephrologists.

NN&I: Were you surprised—or disappointed—that Rogosin was the only small dialysis organization (SDO) that applied for the demonstration?

Smith: We knew that others had thought about applying. Since we are small, our hope was that we could aggregate our patient numbers with other SDOs. But that wasn’t an option in the first round of applicants.

NN&I: Was this a tough decision to join the demonstration, considering the risk involved for a small organization? How did you come to the decision to apply?

Smith: We looked at it very seriously. We didn’t think we could take on the two-sided risk because of our size and relatively greater liability risk. But by being on the one-sided risk pool only, it meant we had to show a higher savings––about 4.5% over CMS’s estimated baseline cost for our patients––in order to be a part of the CEC’s shared savings program.

NN&I: Are there some unique partnerships that you think your ESCO brings to the demonstration?

Smith: Care coordination is important for all the ESCOs. We have made that part of our model as well and it has been a big element in our program. We have also learned more about tracking medications use. We hired someone to help us with the overall management of our ESCO, care coordinators, and a high-level dialysis-unit manager.

NN&I: With the demo now almost a year old, what have you learned from the project? Have there been unexpected obstacles and risk along the way?

Smith: We knew it would be difficult; we can’t say yet financially where we are. One very encouraging outcome for us, and I think for all of the ESCOs, is the willingness of CMS to listen to our thoughts on the demonstration. They really want this to work.

NN&I: Can you share some preliminary data with us on how patients are doing?

Smith: It is still a bit early for that. We are evaluating our problems and successes to date. Next year, there will be a number of quality measures that we will have to report on.

NN&I: Is this a viable approach to providing care for small companies like Rogosin? Can you competitively offer similar—or better—services than the LDOs?

Smith: Participating in the demonstration has caused us to look at a lot of things that we didn’t review before. We are now looking more closely at depression among our patients, for example. We are spending more time focused on coordinating medication usage with other non-nephrologists.

NN&I: How about tracking patients still in CKD 2-4, prior to kidney failure?

Smith: Although it is not part of the demonstration, we have established a Renal Management Clinic to manage patients in CKD Stage 4-5, and some Stage 3 patients. In the long run, if we are going to do a better job of taking care of patients and prevent disease progression, as well as lower costs, we need to do it upstream. We need to go out into the communities and find these patients. Early diagnosis and management of chronic kidney disease and its risk factors are important. In addition, if you can help some of the patients take more responsibility for their own health, including changing their lifestyles, you have a better chance of decreasing the progression of chronic to end-stage kidney disease and increasing the quality and productivity of many lives.