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Building blocks for integrated care
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Thirteen organizations participating in the Comprehensive ESRD Care Demonstration completed their second year of a 5-year demonstration in 2017. This initial group of CMS-approved ESRD Seamless Care Organizations performed well in the first year, showing a shared savings of more than $70 million when compared with baseline Medicare expenditures for the patients enrolled in the project.
A second group of ESRD seamless care organizations began operations in January 2017. CMS is scrutinizing the first-year data from that demonstration and we should know more about their performance in the coming months. All told, 37 ESCOs are now part of the demonstration. The intent of the Comprehensive ESRD Care (CEC) demonstration is to determine if a more wholistic approach to caring for individuals with end-stage renal disease both improves care and saves money.
“Dialysis clinics, nephrologists and other providers join together to create an ESCO to coordinate care for matched beneficiaries,” according to the CEC website. “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 aligned ESRD beneficiaries.”
Changes ahead
For the second year of the demonstration, important changes that are part of CMS’ evaluation process start. The ESCOs will report on how well they perform on a set of quality measures. In the first year, the organizations simply had to indicate they performed the tasks outlined in the measure, ie, provided patients with diabetic foot checks or ensured patient satisfaction surveys were performed. The quality measures included in the demonstration are atypical compared to the Quality Incentive Program that CMS uses to evaluate dialysis care each year. With a more comprehensive approach to patient care in the ESCOs – and an acceptance of complete care of the patient – the ESCO 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,” according to the CMS website. CMS updates the quality measures yearly.
In the second year of the demonstration – 2017 for the first 13 ESCOs – CMS will evaluate how the organizations performed. How an ESCO performs in this evaluation will influence how much of the sharing savings they keep in year 2. Even if the ESCO performed well last year, it could face different quality measures the following year.
Value of improving outcomes
Most dialysis organizations agree the ESCO platform is likely to be how Medicare will pay for dialysis services in the future. The reactive, fee-for-service approach that pays for procedures performed rather than for the outcomes delivered is fading from the health care payment landscape – not only for health care organizations but also for physicians. Accountability is the key word, and payments will be anchored to outcomes.
Several dialysis organizations have embraced this approach and have thrown their support behind the Dialysis Patient Access to Integrated-care, Empowerment, Nephrologists, and Treatment Services (PATIENTS) Demonstration Act. The legislative proposal would allow dialysis organizations to build their own integrated care networks without CMS’ building blocks and the ESCO infrastructure. Some are concerned about rushing to build these networks before the CEC demonstration is complete. Should we wait until results are in?
“The program would utilize the dialysis facility as a central command point for patients to access coordinated health care services,” notes Fresenius Medical Care in educational materials on their website in support of the PATIENTS Act. “This practical approach to care delivery would significantly improve health outcomes and increase quality of life for ESRD patients while reducing costs to the system through reduced hospitalizations and readmissions.”
The key to success for integrated care is a delivery of improved outcomes at a reduced cost. CMS tells us that although individuals with kidney disease represent less than 1% of the Medicare population, they use up 7.1% of the Medicare budget. In 2015, it was $33.9 billion. At the urging of Congress, CMS wants to see a more equitable balance. The second year of the demonstration, with a closer look at performance in quality measures, may provide a clear answer on how that balance can be accomplished.
- References:
- https://fmcna.com/the-dialysis-patients-demonstration-act
- https://innovation.cms.gov/initiatives/comprehensive-esrd-care
- For more information:
- Mark E. Neumann is Editor-in-Chief of Nephrology News & Issues.