End-Stage Renal Disease Alternative Payment Model Shows Promise

Sept. 5, 2019
Report finds CEC model led to reductions in hospitalizations, readmissions, ED visits

An annual report about the Center for Medicare & Medicaid Innovation’s Comprehensive End Stage Renal Disease Care (CEC) model, said it led to lower spending, improvements in some utilization measures, and no obvious indicators of unintended or adverse consequences.

The CEC Model is an Advanced Alternative Payment Model (A-APM) that creates financial incentives for dialysis facilities, nephrologists, and other Medicare providers to coordinate care for Medicare beneficiaries with ESRD. Because the CEC Model was deemed an A-APM, participating nephrologists could exempt themselves from reporting requirement and payment adjustments under MACRA’s Merit-based Incentive Payment System (MIPS).

In the 37 ESRD Seamless Care Organizations  (ESCOs), dialysis clinics, nephrologists and other providers have joined together to coordinate care for matched beneficiaries and are accountable for clinical quality measures and financial outcomes. All dialysis organizations and their associated ESCOs established formal financial risk-sharing partnerships with nephrologists, as required for participation in the CEC Model. Nationally, 12 percent of dialysis facilities are now participating in the model.

 The report, prepared by The Lewin Group Inc. for CMMI in September 2019, found that the CEC model involving ESCOs led to a decrease in Medicare spending of almost 2 percent. “The spending reductions were most evident in Medicare Part A with significant reductions in acute inpatient, readmission, and institutional post-acute care categories,” the report said. “Reductions in utilization paralleled the spending reductions, with significant declines in the likelihood of hospitalizations, readmissions, and ED visits. The number of dialysis treatments and spending on dialysis increased, which could be a consequence of fewer missed treatments, while hospitalizations for and spending on dialysis complications declined.”

 Improving coordination of care across institutional settings was cited as a key objective by the ESCOs, backed by new investments such as care coordination staff and IT. Reducing hospitalizations and readmissions was a particular area of emphasis.

The report said that many ESCOs sought to improve communications with local emergency departments, in order to divert patients with conditions such as fluid overload from the inpatient setting. This improved communication was sometimes coupled with enhanced provision of standby dialysis slots to facilitate rescheduled or extra treatments in such cases.

In addition to the CEC Model’s positive results relative to similar beneficiaries in fee-for-service Medicare, the report highlighted that the CEC Model had superior results relative to primary care-based ACOs. Beneficiaries with ESRD in primary care-based ACOs appear to have experienced no statistically significant impacts relative to the FFS comparison group, suggesting that beneficiaries with ESRD may fare better in the specialized CEC Model than being mixed into a primary care-based ACO population. Given the regular and frequent contact with both the dialysis facility and the nephrologist, as well as the clinical complexity of the ESRD population, a specialty-oriented care model like CEC may be more appropriate and effective for this subset of patients than a more general primary care-based ACO model.

The biggest player in the five-year ESCO program is Fresenius Medical Care North America (FMCNA), a vertically integrated healthcare company focused on renal care that includes a network of 2,400 dialysis facilities and an insurance company that allows it to participate in new models of value-based care that take full responsibility for the patients it serves. The company began transitioning to value-based care more than five years ago. “We truly believe that the value-based care arrangements we are in provide us with an opportunity to provide better care to patients and improve their experience of care,” said Terry Ketchersid, M.D., a nephrologist who is senior vice president and chief medical officer of the Integrated Care Group of FMCNA.

Speaking at a conference earlier this year, Ketchersid noted that ESRD patients spend up to 12 hours per week in dialysis clinics. “We have established phenomenal relationships with those patients. Now we are able to leverage that relationship as we make changes in care that are necessary to succeed in a value-based world,” he explained.

ESCO nephrologists can spend time thinking about what is happening to their patients during the time they are not in dialysis. “In a fee-for-service world, we are laser-focused on providing a safe, effective treatment, but we don’t spend a lot of time thinking about what decisions and barriers patients face outside our clinic,” Ketchersid said. In the value-based care world, if a patient is missing dialysis sessions, a social worker can conduct cognitive behavioral therapy to solve housing or nutritional issues and the patient can spend far less time in the emergency department and may not be admitted as often. “Outside of the value-based care environment, we can’t fund the infrastructure to deliver that kind of care,” he noted. “It is one of the valuable opportunities that exists within these programs.”

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