Since the completion of the Centers for Medicare and Medicaid Services’ end-stage renal disease (ESRD) demonstration projects, passage of the Affordable Care Act, and announcement of ESRD Seamless Care Organizations (ESCOs) by CMS’ Innovation Center, it seems that ESRD-centered accountable care organizations will be the future model for kidney care of Medicare beneficiaries. Regardless of what you call it—managed care organization, special needs plan, ESCO—balancing quality of health care with costs of health care will continue to be the primary directive for physicians and institutions using integrated care management (ICM) strategies to manage their ESRD patients’ health. The renal community has had previous success with ICM, and these experiences could help to guide our way.
The long and winding road: Integrated ESRD care comes of age
It has been more than four decades since Congress passed the Social Security Amendments of 1972 to extend Medicare coverage to patients with end-stage renal disease (ESRD) who need transplantation or renal replacement therapy to sustain their lives. At present, the numerous prescription medications, frequent hospitalizations, and re-hospitalizations impacting ESRD patients may offer a perfect opportunity to demonstrate the value of integrated care. Previous efforts, such as the demonstration project conducted by DaVita and Senior Care Action Network Health Plan (SCAN), were successful in improving quality for ESRD patients. In 2011, this program was converted into a Centers for Medicare and Medicaid Services (CMS) Chronic Condition Special Needs Plan (SNP) to continue to serve patients with ESRD (see Table 1).
Come together: Successful elements of a contemporary ESRD SNP
Under the DaVita/SCAN ESRD SNP, care managers use an integrated care management system to manage comorbidities with evidence-based care pathways to provide education and preventive care. Subprograms, involving both care management and dialysis clinic resources are used for screening and caring for specific comorbidities. One such example, the diabetes management program StepAhead™, is focused on patient education and diabetic care. The first iteration of this program has efficiently educated patients on foot care and blood glucose, and included processes to ensure patients received specialized physician care.1 After 12 months of program participation, the large majority of StepAhead patients received retina and eye examinations (93.0%), physician care for diabetes management (94.8%), and a blood glucose monitor and training to use it (94.8%), and a considerable proportion of patients had received 12 or more foot checks (28.4%). Regarding the use of evidence-based care pathways, other ESRD SNP programs have focused on optimizing vascular access and minimizing the use of central venous catheters.2 Moreover, home dialysis modalities and kidney transplant education is also conducted with the appropriate patients to afford the best renal replacement therapy for each individual. Other programs include advanced directive care planning, vaccinations for influenza and pneumococcus, and focus on traditional dialytic treatment concerns such as anemia, diet, and mineral and bone disease. Such key clinical measures are monitored regularly for both the ESRD SNP members as a whole and the individual participants, and are provided to the care teams (see Table 2).
A secondary focus of care managers is on prevention of hospitalizations related to excessive fluid accumulation between dialysis sessions. The Weigh to Go program educates patients on interdialytic weight gain and provides patients with tools to manage it—including a scale. The intended goal is to minimize fluid-related hospitalizations in the most susceptible patients. Integral to this program is monitoring the use of medications that can impact patients’ blood pressure, fluid status, and serum potassium level, including angiotensin-converting enzyme inhibitors and angiotensin receptor blockers.
These programs fall under the Most Vulnerable Patients (MVPs) umbrella program. MVP uses an intensively focused care team consisting of lead VillageHealth nurses, nurse practitioners, social workers, and registered dietitians who work together to assist the most ill patients within the SNP. Patients are identified as individuals who have been hospitalized frequently and by their acuity level. Root cause analysis is performed to identify the specific underlying issue most likely driving the patient’s hospitalizations to generate an individualized care plan that is systematically monitored to ensure implementation by the team.
A hospital readmission prevention program is also in place with dedicated nurse practitioners to help manage the transition from inpatient to outpatient care. The program uses the most recent technology available including a secure phone texting application that allows care teams to communicate effectively in real time to manage transitions of care.
Lastly, the program includes a comprehensive pharmacy management program. ESRD SNP pharmacists conduct quarterly reviews of members’ medications to monitor adherence and to avoid or rectify problems experienced by ESRD patients who require many daily prescription medications. The combination of pharmacy and clinical monitoring, and patient care coordination with patient education provide an added bonus to many patients—personal empowerment through active participation in health care to drive desired outcomes. The overall high level of patient engagement with the ESRD SNP program is evidenced by a 2013 survey of California SNPs, where it scored highest in consumer satisfaction.3
Getting better: ESRD SNP clinical and financial results
For ESRD SNP patients, metrics around these clinical and administrative programs are regularly assessed to assure basic standards of care are maintained and to identify areas for continued improvement (see Table 3). Primary to outcomes in hemodialysis patients is optimal vascular access; through the SNP, we saw an improvement in fistula placement (2010: 70.3%; 2013: (79.2%), while the proportion of patients using catheters for vascular access fell between 2010 (7.3%) and 2013 (5.4%). These ESRD SNP findings compare favorably to the 2006 KDOQI benchmarks of catheter and fistula use for permanent hemodialysis vascular access,4 as well as the current vascular access modalities reported through the CMS Quality Incentive Program (see Table 3).
The frequency of patient vaccinations for influenza and pneumonia was high in 2010 and 2013?in excess of 95% (see Table 3). Another good indicator of the success of SNP patient care managers is the great improvements in advance care plans. In 2013, 86% of enrollees had advance care plans on record compared to only 25% in 2011. Thus, when the need for hospitalization does arise, patients are not over-treated and cared for according to their directives.
During the execution of the DaVita/SCAN demonstration project and following its transition into an ESRD SNP, program costs have been evaluated to monitor continued feasibility and financial success (see Table 4). Allowable costs generated by ESRD SNP members have been compared to those of the Medicare fee-for-service (FFS) 5% sample. [2014 unpublished third party independent report]After adjustments for age, gender, and relative morbidity, ESRD SNP allowable costs were approximately 3% lower than the FFS in 2008 (p = 0.11), 10% lower in 2009 (p = 0.04), 7% lower in 2010 (p = 0.08), 11% lower in 2011 (p < 0.01), and 5% lower in 2012 (p < 0.01).Although the 2013 Medicare FFS 5% sample was not available at the time of analysis, estimates indicate that 2013 SNP patient costs were approximately 11% lower than the projected costs for the 2013 Medicare FFS 5% sample. With the exception of 2012, there were progressively larger reductions in annual overall cost savings. It is possible that this result was due to an above-average increase in kidney transplants (a positive outcome) that resulted in higher medical costs for ESRD SNP plan members (the range of 2012 quarterly patient numbers was 640-732).
The non-dialysis costs of SNP participants generated an approximate cost savings of 5% in 2008, 15% in 2009, 16% in 2010, 17% in 2011, 8% in 2012, and (projected) 16% in 2013 compared to the Medicare FFS costs for each respective year. A large proportion of the annual reductions in plan costs relative to Medicare FFS costs are probably attributable to reductions in inpatient costs, which were lower by 7% in 2008, 18% in 2009, 15% in 2010, 17% in 2011, 1% in 2012, and (projected) 11% in 2013. The cost pattern follows a similar trend for inpatient days, which are described in Table 4. It is also notable that each year the annual costs associated with dialysis services for ESRD SNP patients were equal to, or slightly greater than, those for patients in the Medicare FFS 5% sample (not shown). This result can be seen as further evidence that patients who can avoid long hospitalizations or even reduce the number of necessary hospitalizations would have the greatest dialysis services costs.
The results of this analysis demonstrate that patients participating in the ESRD SNP experienced lower overall costs relative to their FFS counterparts in the years studied. Over the same time period, clinical quality measure thresholds and reduced hospitalizations were achieved, indicating that high-quality health care was not sacrificed for cost savings. The reduction in costs plus the achievement of the quality targets suggests that the ESRD SNP method of delivering integrated care is effective.
These data demonstrate that ESRD SNPs can provide high-quality, coordinated, comprehensive care focused on preventing complications and managing comorbid conditions to stem the high morbidity, mortality, and health care resource utilization in the ESRD population. These disease management methods are designed to provide improved communication across care teams and disciplines. To do so, it was necessary to use significant resources to bridge the fragmented FFS care delivery system. Despite the additional direct and indirect expenses for ESRD SNP patient program development, participants were treated cost effectively while meeting quality targets.
I’ll follow the sun: ESRD Seamless Care Organizations
While this ESRD SNP has demonstrated success, CMS has not provided widespread authorization of SNPs for ESRD patient management (see Table 1). However, the Patient Protection and Affordable Care Act of 2010 gave CMS the authority to create the CMS Innovation Center, which has been charged with developing novel payment and service delivery models to reduce program costs and enhance quality of care for beneficiaries of Medicare, Medicaid, and Children’s Health Insurance Program. In 2013 the Innovation Center announced a new Comprehensive ESRD Care Initiative called ESRD Seamless Care Organizations (ESCOs).5 Through ESCOs, CMS will collaborate with groups of health care providers and suppliers to treat Medicare patients with ESRD using an integrated care management (ICM) model. ESCOs must be led by care providers experienced in treating beneficiaries with ESRD, and participants must include at least one independent nephrologist or nephrology group practice, with flexibility to include or not include a non-nephrologist health care provider. Both large dialysis organizations (LDOs) with 200 or more dialysis facilities and non-LDOs will be eligible to participate. CMS will offer 2 payment methods that can be applied according to the size of the dialysis facility. ESCOs that include at least one dialysis facility owned by an LDO must participate in a risk-based payment arrangement over the life of the model. ESCOs will be economically and clinically responsible for all care offered to ESRD Medicare patients, including dialysis and care to treat all aspects of kidney disease and other illness. As a beneficiary protection measure, ESCOs must include a governing body with at least one patient representative or independent consumer advocate.
As under the current CMS ESRD Quality Improvement Program, participating ESCOs must report on care delivery and outcome measures. Currently the variables for quality measures are not finalized, although the expectation is that the chosen metrics will measure patient quality of life, diabetes and cardiovascular disease management, infections and hospitalizations, vascular access, and prescription medications.5 ESCOs that succeed in offering high quality care while lowering Medicare Parts A and B costs for patients will share in Medicare savings with CMS.6
The 2014 ESCO application deadlines for LDOs and non-LDOs have passed, so the community must now wait and see how they will fare.
All together now: Conclusions
These results suggest that this iteration of ICM, an ESRD SNP, is a viable approach to improving ESRD patient care cost effectively, and in a manner that facilitates quality. Although it is yet to be determined whether they will be adequately scalable, the nephrology community is anxious to see whether ESCOs are a viable mechanism to extend the many benefits of ICM afforded by SNPs to a larger ESRD patient population—a treatment solution that our complex patients would surely welcome.
1. McMurray S, Ordway C, Colson C, Oberai P, Bubb A. Effectiveness of the diabetic StepAhead program in improving patient care among diabetic ESRD patients. J Am Soc Nephrol. 2013;24:SA-PO376.
2. Wilson SM, Mayne TJ, Krishnan M, et al. CathAway fistula vascular access program achieves improved outcomes and sets a new standard of treatment for end-stage renal disease. Hemodial Int. Jan 2013;17(1):86-93.
3. Medicare and You. 2014; http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2014-C-and-D-Star-Ratings.zip. Accessed Aug 5, 2014.
4. National Kidney Foundation.Clinical practice guidelines and clinical practice recommendations for 2006 updates: hemodialysis adequacy, peritoneal dialysis adequacy and vascular access. Jul 2006. 1523-6838 (Electronic)0272-6386 (Linking).
5. Draft Comprehensive ESRD Care (CEC) Measure Set. 2014; https://www.impaqint.com/draft-comprehensive-esrd-care-cec-measure-set. Accessed July 8, 2014, 2014.
6. Comprehensive ESRD Care Initiative (ESCO) 2013; http://innovation.cms.gov/initiatives/comprehensive-esrd-care/. Accessed July 8, 2014.