The Centers for Medicare & Medicaid Services had limited success in keeping small dialysis providers and payers at the table in two previous demonstration projects looking at alternative payment models. But with the new Comprehensive ESRD Care demonstration, it’s not throwing in the towel again.

The agency has re-opened the application process for the five-year project, hoping to add more small dialysis providers to the 13 already-approved sites that began working with the model last October. CMS reviewed details of the request for proposal (RFP) during a webinar on May 31. The deadline for submission is July 15.

In the care model, dialysis clinics, nephrologists and other providers join together to create an End-Stage Renal Disease Seamless Care Organization (ESCO) to coordinate care for matched beneficiaries. ESCOs are accountable for clinical quality outcomes and financial outcomes measured by Medicare Part A and B spending, including all spending on dialysis services for their patients.

But smaller providers have shied away from the project because of the potential for “downside risk.” If patient care costs more during the demonstration compared to agency’s baseline costs, that provider would have to make up the difference. Only one of the 13 ESCOs––Rogesin Kidney Care Alliance––applied and received approval for an ESCO last year. Fresenius Medical Care has six ESCOs in the demonstration; DaVita Kidney Care and Dialysis Clinic Inc. each have three.

In the revised, Round 2 application, smaller providers now have the option to accept that risk––and potentially earn more savings from the more efficient care they deliver––or decline that risk and accept a lower return. CMS believes offering that option will encourage smaller providers to join. “Smaller providers have the option of participating in a one-sided track where they will be able to receive shared savings payments, but will not be liable for payment of shared losses; or, participating in a track with higher risk and the potential for shared losses,” CMS wrote on the CEC website.

Important dates for the Round 2 application process

May 19: Applications available at

June 8: CMS will host a webinar, “The ESCO Experience.” Register here

July 15: Applications due to CMS

September: applications approved

January 2017: New ESCOs begin

More information available on the CEC demonstration at

Patients are selected for each ESCO based on a “first touch” rule (patients who have been treated at that clinic at least once in the past year are candidates) and ESCOs must have at least 350 patients in their service area (smaller providers have the option to join with other providers in other service areas to meet the patient minimum). Each ESCO must have at least a nephrologist or nephrology practice and one dialysis provider as part of the entity.

CMS will have a recording of the May 31 forum available, along with the slides from the presentations, at Questions about the application process can be emailed to CMS at