Mixed Verdict on ESRD ACOs

How successful accountable care organizations (ACOs) have been in bringing about value-based care hinges, of course, on how success is defined. CMS’ comprehensive end-stage renal disease (ESRD) care model is a good example.

It was launched in October 2015 to improve quality of care for people with ESRD and to cut CMS spending on that care in the process. Initially, 13 ESRD seamless care organizations (ESCOs) participated. The ESCOs consisted of dialysis centers, nephrologists and other providers. They operated much like the ACOs anchored in primary care but were exclusively for people with ESRD and the specialists who provide their care.

Large dialysis companies such as Fresenius, DaVita and Dialysis Clinic participated in some of the ESCOs They brought scale to the program. In the program’s fifth and final year, each ESCO had, on average, 35 dialysis centers and approximately 62,500 people with ESRD were being taken care of by ESCO providers.

A CMS two-page summary of the lengthy evaluation report prepared by the Lewin Group highlights some positive results. From October 2015 through December 2020, the Medicare beneficiaries in the ESCOs experienced 5% fewer hospitalizations from ESRD complication than those not in the ESCOs.

Care in an ESCO was associated with 9% improvement in adherence to taking phosphate binders, drugs that people on dialysis are prescribed to control phosphorous levels in the blood because high phosphorus levels cause kidney damage. Care in the ESCOs was also associated with a modest improvement in patient survival. The summary also says the ESCOs reduced Medicare spending by $88 per beneficiary per month.

However, those cost savings do not include the shared savings payments CMS made to the ESCOs for meeting quality and financial benchmarks. Information about the shared savings payments for all five years is not available, but according to the evaluation report done after the fourth year, the shared savings payments to the ESCOs swung a $151 million reduction in Medicare spending to a $46 million increase in spending (“aggregate net losses”).

Those losses are seen by some as a worthwhile investment that results in improved patient care. But if the goal was to save the Medicare program money overall, it was not met.

The evaluations suggest that the ESCOs did produce better outcomes for people with ESRD, and CMS has launched a new kidney care program called Kidney Care Choices that builds on some elements of the ESCOs. The new program is broader program and includes people in early stages of kidney disease.