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Compared With Primary Care ACOs, ESRD Model Excelled in First Year


A study found that patients in the Comprehensive End-Stage Renal Disease (ESRD) Care Model saw a decrease in hospitalizations and readmissions compared with the accountable care organization (ACO) model.

A new study finds that the first Medicare accountable care organization (ACO) relying on kidney care specialists rather than primary care providers did a better job at keeping patients with end-stage renal disease (ESRD) out of the hospital or from being readmitted.

Medicare payments also declined, according to the study, published in Health Affairs Monday. It built on earlier studies examining outcomes of patients with ESRD enrolled in the the Comprehensive ESRD Care (CEC) Model, but this time compared findings with the performance of primary care ACOs.

CMS launched the CEC model in October 2015, as patients with ESRD require more complex and expensive care than the general population of Medicare beneficiaries. Less than 1% of patients on fee-for-service (FFS) Medicare had ESRD in 2018, but they accounted for more than 7% of total FFS payments, the authors noted.

To encourage a shift away from FFS while delivering more coordinated care, the model created financial incentives for dialysis facilities, nephrologists, and other Medicare providers to form ESRD Seamless Care Organizations (ESCOs).

Investigators used Medicare Parts A and B enrollment and claims data from January 1, 2014, to December 31, 2019. The data were linked to the ESRD Medicare Patient Registration data, which contained dialysis start date, cause of ESRD, and pre-ESRD nephrology care.

Monthly Medicare parts A and B payments and service-level payments were calculated for both the CEC model and ACO intervention group. Utilization was measured as number of hospitalizations, which included first admissions, readmissions, and emergency department (ED) visits per month.

Patients were excluded if they did not have 12 consecutive months of FFS Medicare enrollment, did not receive most of their services from the same dialysis facility for the entire study period, or if ACO and FFS Medicare beneficiaries began receiving care through an ESCO at any point during the study period.

There were 21,100 participants in the Comprehensive ESRD Care Model; 11,153 participants in primary care ACOs; and 32,253 matched comparison beneficiaries. The intervention period ran for 12 months.

The number of hospitalizations for participants in the CEC model declined by 5.6 per 1000 participants per month, or roughly 5%, in the first year compared with the matched comparison group.

Likelihood of readmission within 30 days of hospital discharge decreased in participants in the CEC model by 1.8 percentage points, or 87.6%.

Medicare payments fell by $126 per beneficiary per month in the CEC model, or about 2.3%, compared with before the model was put in place.

Fistula use increased in CEC participants, but the authors said the findings were just above the threshold of statistical significance.

There were some limitations to this study. Participation in alternative payment models is voluntary, so the ability to generalize results are limited. The characteristics selected for matching may not have included all differences between intervention and comparison groups. The ESRD beneficiaries in this study may not represent all patients with the disease, and impact estimates were limited to the first year of alignment.

The researchers concluded that their research has policy implications for other Medicare populations with chronic disease, considering the benefits of specialty-focused ACO models. In addition, primary care ACOs could benefit by adopting some of the strategies used by ESCOs to care for high-need patients, they said.


Ullman DF, Boyer GJ, Negrusa B, Hirth RA, Wiens J, Marrufo G. Medicare’s specialty-oriented accountable care organization: first-year results for people with end-stage renal disease. Health Aff (Milkwood). 2022;41(6):893-900. doi:10.1377/hlthaff.2021.01856

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