It’s a mixed bag.

The Centers for Medicare & Medicaid Services released the quality improvement and financial results from the second year of the agency’s Pioneer and Shared Savings Accountable Care Organization demonstration last month. The results suggest that some work needs to be done to help providers reduce the risk, but the outcomes show some promise.

Here is what they found, as reported by the journal Modern Healthcare:

Financials. In year one of the three-year demonstration, health spending slowed around 7% among some ACOs and accelerated as much as 5% for others. In the second year, health spending slowed around 5.4% among those that reduced patients’ medical bills and accelerated as much as 5.6% where costs escalated.

Overall, between the Pioneer and a less risky Shared Savings Program model, there was a reduction in Medicare spending of $817 million, with hospitals and doctors keeping $445 million for their efforts. Eleven of 23 Pioneer ACOs earned financial bonuses that totaled $68 million during the program’s second year.

But there is room for improvement. “Of the 32 original Pioneers ACOs, 23 of them spent no less on Medicare patients than local markets to which they were compared,” noted Joe Damore and Wes Champion in a August 21 Health Affairs blog post. “Taken together, the 32 Pioneers produced $20 per beneficiary, per month savings for Medicare had the individuals not been aligned to an ACO. That’s $240 per person a year–maybe the cost of a single prescription for a month.”

Quality of care. Performance on quality improved for 28 of 33 measures. Quality measures included getting timely care, appointments, and information; screening for fall risk; influenza immunization; tobacco use assessment and cessation, and depression screening.


There was high attrition. Of the 32 Pioneer ACOs that started in the demonstration, nine exited in the first year; eight of those said their costs skyrocketed during that time. Four more Pioneers dropped out after the second year.

Launching a renal ACO

January is still the target date for the renal community’s first foray into accountable care. September 15 was the final deadline for small- and mid-sized dialysis providers to apply to the Comprehensive ESRD Care demonstration. Larger providers were required to submit their applications this summer.

CMS had revamped the application after listening to complaints from the renal community about the high risks and low rewards.  Despite a genuine interest in developing an integrated care model that works, and CMS’s willingness to make changes, concerns remain. ““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.

And if we are talking about a global approach to treating kidney disease, why are we skipping CKD?  Integrated care offers the idea of intervening early and slowing the progression of the disease.  It should be part of the demonstration. In an extensive interview with Modern Healthcare, DaVita Healthcare Partners Chief Medical Officer Allen Nissenson, MD, said the renal ACO demo could have been designed to do so much more. “It’s critical to move upstream and start looking at chronic kidney disease (CKD) patients before they reach end-stage disease. …We really believe in the accountable care organization approach. We would have liked to do this much more broadly. But there are some issues around the way the financing is done and other important issues in terms of the regulations. We’re enthused but kind of sad that the full potential (of the renal ACO model) probably won’t be realized.”

Quality measures

Renal providers are still waiting for quality measures to be approved for the renal ACO demonstration. CMS had released a draft set of measures that included patient satisfaction; preventive efforts in managing diabetes; tracking the use of ACE inhibitors or ARB therapy for managing heart disease, along with the use of beta blockers to help manage coronary artery disease; use of a dialysis facility risk-adjusted standardized mortality ratio; tracking immunizations and vaccinations, tobacco use, screening for clinical depression, and development of a standardized hospitalization ratio and readmission ratio for dialysis facilities.

The renal care ACO is a great concept; even without including the CKD population, a more integrated approach to caring for the individual with kidney disease is the right way to go. Developing a model that fits both small and larger providers will be the key.