DaVita® Medical Insights

Preparing for ESRD Integrated Care

The Centers for Medicare & Medicaid Services (CMS) recognizes that the end stage renal disease (ESRD) population is a complex group in need of integrated care services, as evidenced by CMS’ inclusion of ESRD in Medicare Advantage (MA) Chronic Condition Special Needs Plans (C-SNPs) and its development of the only disease-specific accountable care organization—ESRD Seamless Care Organizations (ESCOs). The benefits of these risk arrangements are already clear: In ESRD C-SNP markets, hospitalization rates are 20 percent lower than the national average and readmission rates are 15 percent lower.[1] As the industry continues to move toward integrated care, is important for healthcare professionals to understand the changes that come with this shift and how to prepare.

National Integrated Care: Advantages and Disadvantages

There are currently 19 ESRD C-SNP markets and 37 ESCOs across the United States and their prevalence is rapidly increasing: The number of ESRD C-SNPs doubled between 2013 and 2016. Delivering ESRD integrated care on a national scale comes with advantages and specific challenges. C-SNPs offer risk-adjusted monthly Medicare Advantage (MA) payments, flexibility in defining a service area and a Part D drug benefit with an ESRD-tailored formulary—yet they are costly to start, have low enrollment totals and require a payer partner, which can be difficult to find.  ESCOs have attribution defined by the government, performance-based payments and shared savings, and use of a fee-for-service network. Unfortunately, ESCOs are not scalable in all geographies. They also require significant upfront investment, mandatory risk-taking for nephrologists, and return of a large majority of the shared savings returned to the government. Moreover, ESCOs are subject to regular changes in CMS methodology in calculating ESCO performance.

The coexistence of ESCOs and C-SNPs acknowledges that neither is perfect. It is also certainly possible that additional vehicles for integrated care will be created for ESRD patients to join ESCOs and SNPs, just as we have seen multiple forms of value-based reimbursement come into play for non-ESRD patients.

Preparing for ESRD Integrated Care

Healthcare professionals are increasingly exploring integrated care approaches to incorporate into their practices. The following preparations can occur across offices, dialysis centers and information technology.

The Office:                               

  • Move from physician-focused office hours to patient-centered hours
  • Expand availability to schedule new patients and return visits as needed
  • Increase use of extenders
  • Expand skill set for risk contracting
  • Organize individual patient care plans
  • Develop consistent patient education programs and goals
  • Have an office-based comprehensive care team

The Dialysis Center:

  • Use the DaVita Patient-Focused Quality Pyramid to think more about holistic care
  • Widen the nurse practitioner’s role to participate in transitions of care
  • Increase focus on hospital and nephrology practices
  • Expand the team outside of the dialysis center
  • Discuss integrated care solutions during homeroom meetings

Information Technology:

  • Aggregate and report local, regional and national quality metrics
  • Develop protocols for the practice
  • Analyze patient data trends that could improve care
  • Work with IT vendors to capture meaningful data
  • Initiate protocols for electronic medical record to provide consistent processes and reportable outcomes
  • Use local, regional, national and internal benchmarks to compare outcomes

A 2016 study published in the Journal of the American Medical Association showed that receipt of integrated care could result in higher rates of certain quality care measures, lower rates for select acute care utilization measures and lower costs of care. Associated with enhanced clinical outcomes and patient quality of life, integrated care is the future of medicine.

Read about an effective ESRD integrated care model here.

[1] 2015 USRDS Annual Data Report and 2015 SCAN DaVita C-SNP in Riverside and San Bernardino, CA (~800 enrolled members).


Bryan Becker, MD, MMM, FACP, CPE

Bryan Becker, MD, MMM, FACP, CPE

Bryan N. Becker, MD, is chief medical officer of DaVita Integrated Care and has nearly 20 years of physician executive experience. He received his AB in English at Dartmouth College and MD from the University of Kansas, and, after training at Duke and Vanderbilt, he led the nephrology group at the University of Wisconsin and developed a new kidney care venture called Wisconsin Dialysis, Inc. He also served as CEO at the University of Illinois Hospital and Clinics and president of the National Kidney Foundation. Before joining DaVita Kidney Care, Dr. Becker served as President of the University of Chicago Medicine (UCM) Care Network, a more than 1,000 physician clinical integration organization, and Vice President, Clinical Integration and Associate Dean, Clinical Affairs at UCM. Twitter: @bnbeckermd