Characteristics of Markets and Patients Served by ESRD Seamless Care Organizations

Abstract

Under the Comprehensive End-stage Renal Disease (ESRD) Care (CEC) Model, dialysis facilities and nephrologists form ESRD Seamless Care Organizations (ESCOs) to deliver high value care. This study compared the characteristics of patients and markets served and unserved by CEC and assessed its generalizability. ESCOs operated in 65 of 384 markets. ESCO markets were larger than non-ESCO markets, had fewer White patients, higher household income, and higher Medicare spending per patient. Patients in ESCOs were similar to eligible nonaligned patients in age and sex but differed in race/ethnicity and were more often treated in an urban area; comorbidity prevalence differed modestly. CEC is available to a meaningful share of the dialysis population and relatively few dialysis patients resided in a market where no provider could meet the participation threshold, so market size may not be the primary barrier for potential new participants in CEC or future kidney care models.

Organizational Characteristics Associated with High Performance in Medicare’s Comprehensive End-Stage Renal Disease Care Initiative

“…Our analyses illuminate the heterogeneity in ESCO performance and the wide variation in organization and characteristics of the communities in which ESCOs operate. Our finding that ESCOs tended to form in communities with above-average financial well-being (i.e., high median household income and low percentage Medicaid eligible) and high representation of otherwise under-represented racial/ethnic minority populations (i.e., non-Hispanic Black and Hispanic) is consistent with previous analyses of ESCOs' market characteristics (24). These relationships may be driven, in part, by the CEC Initiative's minimum patient volume requirement ($350 Medicare beneficiaries receiving maintenance dialysis), which limits the geographic distribution of ESCOs to urban and suburban communities (6).…”

Alternative Payment Models and Opportunities to Address Disparities in Kidney Disease

“…Regarding ESCOs, these ACOs were associated with fewer hospitalizations and less catheter usage, 19 and ESCO-aligned patients were more likely to be J o u r n a l P r e -p r o o f Black. 20 Black participants in ESCOs had significant reductions in costs and increases in fistula usage compared with those in matched comparison facilities, whereas white participants did not have significant changes in costs or fistula usage. 21 Taken together, the findings of these initial studies are mixed, and do not yet suggest an overall conclusion of the impact of APMs on kidney care disparities.…”

Fragmentation of care as a barrier to optimal ESKD management

“…In kidney disease, care fragmentation is generated and fostered by (a) a lack of coordination between specialists who manage only one or a few of their patient's medical problems, 9,10 for patients with ESKD. 81,82 For example, patient-centered medical homes, 83 kidney disease specific managed care programs like the Medicare Advantage Special Needs Plans, 84 and ESRD-specific accountable care organizations 85,86 (i.e., ESRD seamless care organizations) may involve co-located clinical care (nephrology specialty care embedded within high-CKD prevalence primary care clinics), with clearly delineated roles and responsibilities for each provider on the care team, 73 and the use of integrated electronic communication systems. 73,82 These strategies may be necessary to improve patient engagement in treatment decisions, facilitate the use of treatment options associated with a higher quality of life, and efficiently deliver safe and effective care to patients with ESKD.…”