After a poor response to its request for applications to the Comprehensive ESRD Care Initiative, the Centers for Medicare & Medicaid Services announced Oct. 25 that it would reopen the application process for the demonstration sometime this winter.

“With this opening, we are particularly interested in creating opportunities for small dialysis organizations to participate and engaging with stakeholders on the quality measures and quality performance benchmarks for the initiative,” CMS said in the statement.

Only one application submitted to CMS—from the Centers for Dialysis Care in Cleveland, Ohio–would be considered a small provider. The other applications have come from Fresenius Medical Care, DaVita, and Dialysis Clinic Inc., the three largest dialysis providers in the country.

Several smaller providers, including Satellite Health Care, Renal Ventures Management, and Atlantic Dialysis Services, all considered applying for the demonstration but withdrew from the process because of the complexity and risk for providers, according to interviews conducted by NN&I.

CMS said updates on the timeline for the new application period would be posted at when they become available.

Through the ESRD Care Initiative, CMS will partner with groups of health care providers and suppliers – ESRD Seamless Care Organizations (ESCOs)—to test and evaluate a new model of payment and care delivery specific to Medicare beneficiaries with ESRD. Participating ESCOs will be clinically and financially responsible for all care offered to a group of matched beneficiaries, not only dialysis care or care specifically related to a beneficiary’s ESRD.

Changing the RFA

It’s not clear what CMS will do to make the demonstration more appealing to small organizations. CMS had reduced the number of required participants in the ESCOs from 500 to 350 at the request of smaller providers.

In a statement issued by patient and health professional organizations on recommendations for improving the framework of the ESCO program, they said CMS should:

  • Continue to emphasize the leadership role of nephrology health professionals in ESCOs.
  • Develop appropriate quality metrics for dialysis patients in a transparent manner that allows for input from the entire kidney community.
  • Prospectively specify the criteria that will determine whether an ESCO is deemed “successful” or “unsuccessful.”
  • Recognize that the patients’ perception of success is an important factor in determining whether ESCOs were or were not successful.
  • Facilitate research into and a better understanding of optimal dialysis care by sharing de-identified ESCO patient data with qualified investigators, in a similar manner to the National Institutes of Health.
  • Develop a plan to ensure consistent access to transplantation, recognizing that the best candidates for transplant are also often likely to be the healthiest patients on dialysis, and will not be attributed to ESCOs post-transplant.
  • Establish and explain safeguards to monitor and address “cherry picking” or potential changes in patient outcomes.
  • Reconsider the goal of rebasing the program in years four and five, recognizing that this approach penalizes the highest performing ESCOs.

The statement was signed by the American Association of Kidney Patients, the American Society of Pediatric Nephrology, the Renal Physicians Association, the American Kidney Fund, Renal Support Network, Dialysis Patient Citizens, the American Society of Nephrology, and the American Nephrology Nurses Association.

Other contentious points remain on the demonstration for both large and small providers, including:

  • Shared savings. Dialysis providers are not convinced they will be able to recoup their cost of setting up and operating the ESCOs with the split in shared savings that CMS offers for the demonstration.
  • Rebasing. CMS recalculates the benchmark in the payment formula after the third year in the demonstration, but dialysis providers say ESCOs will be treating many new patients in the fourth year because of the high mortality rate in the ESRD Program. New, more fragile patients will cost providers more to treat during a time when the benchmark in the payment formula offers lower rewards.
  • Expanding the ESCOs.The demonstration doesn’t allow the ESCOs to expand to other service areas during the five years of the project.
  • Quality metrics. CMS has yet to establish the quality metrics that will be used to determine provider performance.

Questions about the Comprehensive ESRD Care Initiative application, or the initiative generally, can be sent to