DaVita® Medical Insights

3 Learnings from the ESCO Demonstration Model to Help Improve Care and Outcomes

End stage renal disease (ESRD) care is often fragmented, with multiple specialists managing multiple conditions across multiple care settings, often without continuous communication. This can result in patients struggling to navigate the complex health care system on their own.

To address care delivery to these patients, over the past decade the Centers for Medicare & Medicaid Services (CMS) established several demonstration programs, including the first CMS disease-specific accountable care organization—the ESRD Seamless Care Organization (ESCO). ESCOs allow nephrologists, dialysis centers and other providers to partner to test a new care delivery model aimed at improving clinical outcomes and patient experience under a shared savings payment structure.

As with any type of demonstration program, there are features that encourage additional innovation, sharing of lessons learned and the identification of gaps and challenges with the model. With experience participating in ESCO demonstration projects, DaVita has identified the following three areas that could be improved upon to delivery higher quality care within an ESCO.

1. Quality measures

Medicare Shared Service Program (MSSP) accountable care organizations (ACOs) originally reported on 33 quality measures. While ESCOs have fewer quality measures, they focus on several categories meant to capture a patient’s experience of care within the ESCO, improvement in care coordination and patient health outcomes. Yet the connection between the quality measures, ESRD patient health and medical cost reduction is not direct and linear. Given the lead time for chronic conditions in many ESRD patients, it may not be as straightforward as simply expanding quality measures to look at secondary prevention as a means of overcoming this disconnect. It may be appropriate to incorporate different measures related to patient frailty, treatment, expanded screening beyond just mental and behavioral health conditions and using multiple sources of patient-reported data to bolster the relevance of the quality measures in the ESCO program.

2. Market and geography selection

ESCOs are structured similar to the MSSP. As such, one might anticipate a similar trajectory over time: early cost savings in geographies where market-level costs are traditionally high, followed by later improvements in quality. However, not all markets are created equal, and shared savings models work the best where there is greater opportunity for improvement. Geographies where integrated care innovation has taken place prior to the launch of the ESCO model are disadvantaged because those historically significant improvements will not be rewarded or captured in the CEC Model. In addition, markets with healthier populations and lower overall utilization of health care services have much less room for improvement in medical cost reduction and generation of shared savings. Given the high economic hurdles of the ESCO model, this unfortunately excludes many different markets across the country from being considered viable.

3. Partner participation

In the ESCO model, nephrologists are required to take financial risk. If there is a desire to scale the ESCO model more broadly, future models should create flexible options for nephrologist and other provider participation given large variations in practice sizes and the limited capital available for investment by smaller practices across the country. In addition, DaVita believes that bringing multiple practices and providers together, regardless of size, to pursue better patient outcomes is at the core of integrated care. Other mechanisms might still successfully engage nephrologists who may not possess the same risk tolerance or resources as ESCO partners, but who do possess the energy and creativity to contribute to innovative ESRD care. Similarly, alternative models that either incentivize performance or provide a risk-adjusted regular payment, similar to Medicare Advantage plans, can enhance the likelihood of broader patient care management as opposed to a primary focus on acute events alone.


All ESRD patients deserve their best chance at having a quality life, and this is achievable through integrated care. Less than 10 percent of Medicare patients can access integrated care through the models available today. A commitment to providing long-term quality of care for the whole patient can lead to both continued improvements in outcomes for the patients in the ESCOs today, and improved processes and programs for future patients. Dialysis centers and providers are also committed to leading health care delivery reform for the chronically ill and will be ready to participate broadly and nationally if some of the current constraints and learnings from the ESCO structure are applied to the models of the future.


Note: Some of this content has been repurposed, with permission, from Nephrology News & Issues.

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