Accountable Care Organizations: Looking Ahead

The Comprehensive ESRD Care Model was designed by CMS to test new ways to evaluate and improve care for Medicare beneficiaries with ESRD through new integrated care structures—ESRD Seamless Care Organizations (ESCOs)—which added to the knowledge gained through experiences with Medicare Chronic Special Needs Plans (C-SNPs). ESCOs have financial models similar to other Medicare Shared Savings Programs (MSSPs)—specified quality metrics and accountability for the spectrum of care for the patient aside from kidney transplantation.

Patient attribution differs in ESCOs versus MSSPs, as patients are attributed by facility and not by principal provider. This may have an effect of solidifying patient numbers for this type of integrated care vehicle, while reducing patient churn. Care coordination appears to be essential for patients enrolled in ESCOs, facilitating appropriate transitions of care and timely procedures. The opportunity to access claims data for the patients as part of the ESCO program provides a chance to delineate high-value services in domains of care that traditionally have been difficult to understand for the ESRD provider community, such as use patterns for post-acute care facilities.

It will be interesting to compare those results with the initial results from Pioneer accountable care organizations (ACOs) and the MSSP Track 1 models, given the influence of expense reduction and quality of care in early versus later years of MSSP performance.

Despite advances in offering integrated care programs for ESRD patients over the last several years, fewer than 10 percent of Medicare beneficiaries have access to integrated care. Both C-SNPs and ESCOs have potential obstacles to broader adoption. Barriers to scaling ESRD C-SNPs include upfront costs for care management and information transmission infrastructure, the requirement of having a willing health plan partner and low levels of patient enrollments. Spreading costs across the modest number of patients who enroll in an ESRD C-SNP can be economically tenuous. The annual reassessment of Medicare Advantage rates provides additional variability in considering the sustainability of an ESRD C-SNP.

The attribution principles in ESCOs were designed to reduce the possibility of low patient numbers; however, ESCOs entail medical cost risk and financial contribution, inherently restricting the opportunity to providers with significant risk tolerance and with enough of a resource base to contribute to the ESCO. Smaller nephrology practices in the United States delivering exceptional care might not have the same level of enthusiasm for participating in an ESCO under the present regulations. Other challenges include the potential for penalizing historically high-quality providers and frequently restating quality and financial calculations.

Ideal integrated care models in the future would address key issues with the existing models and include the best aspects of SNPs and ESCOs to create a scalable and sustainable model—ESRD tailored benefits, prospective monthly payments, flexible service areas, automatic patient attributions and performance-based payments. The current trends toward value-based care bode well for the future of integrated care. The introduction of MACRA and legislation, such as the Dialysis PATIENTS Demonstration Act and the CHRONIC Care Act of 2017, are a positive indication that many more ESRD patients might be able to benefit from integrated care going forward.

Some of this content has been republished, with permission, from Accountable Care News.