Even with a second round of "fixes" to the original proposal to launch a demonstration testing the accountable care model in renal care, large dialysis providers who have submitted applications still are unclear on how Medicare expects the project to unfold in January.

Key details are still missing on how the Comprehensive ESRD Care model will operate, including the extent of risk that dialysis providers will have to accept, what interventions will be allowed, and what quality measures will be used to judge a provider’s performance.

“The economics are not great, the quality targets are not known and they haven't told us what interventions are going to be dictated by the waivers,” said Robert Sepucha, vice president of corporate affairs for Fresenius Medical Care in an interview with Modern Healthcare’s Sabriya Rice, published Aug. 25.

The quality metrics applied to this patient population have to be specific, he said, because of the multiple comorbid conditions many dialysis patients face.

The Center for Medicare & Medicaid Services’ Innovation Center conceived the new Comprehensive End-Stage Renal Disease Care initiative in February 2013 to investigate new payment and delivery models aimed at reducing costs and improving quality. The initiative is modeled after other ACOs launched by Medicare for other beneficiaries; this demonstration would have providers set up ESRD seamless care organizations, or ESCOs, to coordinate care among multiple specialists. The premise is that by handing over the risk for total patient care to a provider who specializes in kidney disease, better care coordination controlled and managed by the ESCO will provide a continuum of care and save Medicare money. Savings would then be split between the ESCO and Medicare.

Early criticism of the project included a lack of a CKD component to help identify and more aggressively treat kidney disease earlier, the number of patients required to participate in the project, and the risk to providers if costs were higher than the Medicare baseline. Quality measurements were also undefined.

CMS has already published a set of preliminary CEC measures and told Modern Healthcare the final list will be similar. Metrics for quality of life, disease management, mortality rates, and care coordination (like readmission and hospitalization ratios) are included. CMS said it expects to release details on the quality measurement strategy for the initiative in late fall of this year.

CMS has not disclosed the number of applications it has received from providers vying to operate as ESCOs; large dialysis organizations were given through June 23 to submit applications, while small dialysis organizations have until Sept. 15. FMC’s Sepucha indicated in the Modern Healthcare interview the company hopes to operate up to six ESCOs as part of the demonstration; DaVita Kidney Care has indicated they are looking at five applications. Dialysis Clinic Inc., the third largest dialysis provider, has said it has filed three applications.