Specialty-Oriented ACO Improved Outcomes, Spending for ESRD Patients

The Comprehensive End-Stage Renal Disease (ESRD) Care (CEC) Model reduced Medicare payments and hospitalizations among beneficiaries with ESRD, suggesting that specialty-oriented accountable care organization (ACO) models may offer more benefits than primary care-based ACO models, according to a Health Affairs study sent to journalists.

CMS launched the CEC Model in October 2015 as the first specialty-oriented ACO. The model offers financial incentives for dialysis facilities, nephrologists, and other Medicare providers to form ESRD Seamless Care Organizations (ESCOs) to coordinate care for individuals with ESRD.

Under this model, specialty providers take on financial responsibility for the total cost of care instead of primary care providers.

Using claims and enrollment data from CMS, researchers compared spending, utilization, and quality outcomes among ESRD beneficiaries in the CEC Model, beneficiaries in a primary care-based ACO, and those under Medicare fee-for-service.

The analysis reflected data from nearly 65,000 beneficiaries with ESRD from January 1, 2014, to December 31, 2019. The sample included 21,100 CEC beneficiaries, 11,153 primary care-based ACO beneficiaries, and 32,253 matched comparison fee-for-service beneficiaries.

Researchers found that the number of hospitalizations for CEC beneficiaries decreased by 5.6 per 1,000 beneficiaries per month, or a 5 percent reduction. The number of emergency department visits among individuals aligned to the CEC Model did not change significantly.

Under the primary care-based ACO, there were no significant changes in the number of hospitalizations or emergency department visits.

The likelihood of readmission within 30 days of a discharge declined by 1.8 percentage points among beneficiaries in the CEC Model, or an 87.6 percent reduction. Beneficiaries in the primary care-based ACO saw a slight decrease in readmissions as well, but the change was smaller and not statistically significant, researchers noted.

The study measured quality of care changes by assessing methods of vascular access. Catheters are the least preferred form of vascular access due to the higher risks of death, infection, and cardiovascular events. Neither the CEC nor the primary care-based ACO model saw significant changes in catheter use.

Fistulas are the preferred method of vascular access and CEC beneficiaries saw a slight increase in fistula use.

Aside from improving patient outcomes, the CEC Model also reduced Medicare spending. Medicare payments decreased by $126 per beneficiary per month (2.3 percent) in the first year of CEC Model participation. This decrease can likely be attributed to the reduction in hospitalizations and the lower likelihood of readmission, researchers said

Although ESCOs generated reductions in Medicare payments, the CEC Model led to net losses for Medicare after accounting for shared savings payments, the study noted.

Medicare payments for beneficiaries in primary care-based ACOs decreased, but the changes were not significant.

CEC beneficiaries likely saw reductions in healthcare utilization, such as hospitalizations, because they had frequent and regular contact with specialty providers. Meanwhile, individuals aligned with a primary care-based ACO typically had sporadic contact with primary care providers.

“Although results under the CEC Model might not generalize to care models for populations with other chronic illnesses, the CEC Model experience could provide evidence of potential benefits of giving specialty providers increased patient care responsibilities in an ACO context, whether that ACO is composed entirely or partially of a population with a particular chronic condition,” researchers wrote.

Since implementing the CEC Model, CMS has developed more models that focus on improving care for beneficiaries with ESRD. For example, the ESRD Treatment Choices Model promotes home dialysis and transplantation, while the Kidney Care Choices Model focuses on reaching those with ESRD who are not yet receiving treatment.

In the ESRD prospective payment system (PPS) final rule for CY 2022, the agency changed the ESRD Treatment Choices Model to directly address health equity.