With less than 10 entitles signed up for its Comprehensive ESRD Care demonstration––even after two extensions of the submission deadline for applications––the Centers for Medicare & Medicaid Services is contemplating changes to make the model more appealing to the renal community.

CMS said in February, when it released the request for applications for the five-year demonstration, that it wanted 10 to 15 participants. With plans to begin the project in January, NN&I sources say the agency has about nine applications from DaVita, Fresenius, Dialysis Clinic Inc. and Cleveland-based Centers for Dialysis Care, the only mid-sized provider that applied. Once an application is approved, CMS will "match" patients to the ESRD Seamless Care Organizations (ESCOs) that will provide the care. Each ESCO must have at least one nephrologist and one dialysis facility as partners.

In addition to extending the deadline for applicants, CMS has also made some changes based on stakeholder feedback, including removing a requirement for a third Medicare provider in the ESCO and changing the two-sided risk track for large providers. They have also reduced the number of patients needed for participation from 500 to 350. Concerns still remain, however, about the demonstration and risk that providers must accept to participate, according to advocacy groups. They include:

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 its ongoing Pioneer ACO demonstrations for the general population. 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. Rebasing should be removed and benchmarks should be set based on the cost of providing care within the state where the ESCO is operating. Also, dialysis treatment should not be included in setting payment benchmarks because those costs are fixed.

Expansion. The demonstration doesn’t allow the ESCOs to expand to other service areas during the five years of the project. If the demonstration is successful for both Medicare and the ESCOs, providers argue, expanding to more service areas will benefit patients.

Quality Measures. CMS has yet to establish the quality metrics that will be used to determine provider performance. The agency has been putting together technical expert panels to develop measures, but the renal community is concerned about having adequate input before the January launch of the demonstration.  

JV Rule. Providers don’t like a recently added rule that disallows physicians in joint venture agreements with providers to serve as a partner in the ESCO. Most mid-sized dialysis companies use the joint venture model to offer nephrologists a percentage of facility ownership.

“Across the board, there is a lot of interest in integrated care. We think the shared savings model is appropriate for the dialysis population,” said Cherilyn Cepriano, executive director of the Renal Care Council. The group, comprised of most of the renal providers in the country, met with CMS Administrator Marilyn Tavenner in July.  “We have identified as a community some concerns and recommendations that we hope they can use to finetune the model to make it more accommodating to dialysis providers. We do believe dialysis patients are the perfect candidate for ESCOs,” said Cepriano.