The Centers for Medicare & Medicaid Services would like to believe that improving quality can drive cost reductions. That seems logical. Fragmented care leads to higher costs; well managed care, particularly preventive efforts, should reduce hospital stays and slow down disease progression.

The results after two years of the CMS Innovation Center’s Pioneer Accountable Care Organization and Shared Savings Program are in, and they are encouraging. Can they be duplicated in a similar program for kidney patients?

Launching a renal ACO
January is still the target date for the renal community’s first foray into accountable care. Sept. 15 was the final deadline for small- and mid-sized dialysis providers to apply to the Comprehensive ESRD Care demonstration. Larger dialysis 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’ 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 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 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 probably won't be realized.”

Results from ACOs in other specialties
On Sept. 16, CMS released data from the 250 ACOs launched two years ago in both the Pioneer ACO model and Shared Savings Program model. It showed a reduction in Medicare spending by $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. Three faced penalties after health spending accelerated. Performance on quality improved for 28 of 33 measures.

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 Aug. 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.”

Altogether, the Pioneers produced savings of about $147 million, a drop in the bucket for the entire Medicare budget, and certainly much less than the amount spent to develop the infrastructure to support the ACOs, Damore and

Champion wrote. “Officials with the Centers for Medicare & Medicaid Services—which is managing the Pioneer and the Medicare Shared Savings Program (MSSP) ACOs—said some progress is better than none, and the program will take time to produce more significant savings.”

Quality measures
Quality measures have been a point of contention for Medicare’s accountable care effort since it first began. Hospitals and doctors rejected an early proposal for 65 measures, which the CMS shaved to 33. Federal officials earlier this summer proposed an increase to 37 measures with some existing measures to be swapped for others.

Renal providers are still waiting for quality measures to be approved for Comprehensive ESRD Care 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, and screening for clinical depression, and development of a standardized hospitalization ratio and readmission ratio for dialysis facilities.

The Comprehensive ESRD Care demonstration 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.