Is ESCO the Future of Dialysis Care?

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ESCOs are accountable for clinical quality outcomes and financial outcomes.
ESCOs are accountable for clinical quality outcomes and financial outcomes.

Since January 2017, some 10% of the 550,000 dialysis patients in the United States have been managed by 37 ESRD Seamless Care Organizations (ESCOs) participating in the Comprehensive ESRD Care (CEC) Model. The CEC Model was designed by the Centers for Medicare and Medicaid Services (CMS) to identify, test, and evaluate new ways to improve care for Medicare beneficiaries with ESRD. The first round of the ESCO project is expected to end by 2020.

Dialysis patients receive treatment at some 7,000 dialysis units in the country. Each year, more than 110,000 patients with advanced CKD transition to dialysis therapy in the United States. Through ESCO, CMS partners with health care providers, including nephrologists, as well as dialysis organizations, to test the effectiveness of this new payment and service delivery model in providing beneficiaries with what is expected to be a patient-centered approach with a higher quality of patient care.

The ESCO model builds on the Accountable Care Organization (ACO) experience. As CMS states on its website, “ESCOs are accountable for clinical quality outcomes and financial outcomes measured by Medicare Part A and B spending, including all spending on dialysis services for their aligned ESRD beneficiaries.” The model encourages dialysis providers “to think beyond their traditional roles in care delivery and supports them as they provide patient-centered care that will address beneficiaries' health needs, both in and outside of the dialysis clinic.”

It is generally believed that improved outcomes, such as lower hospitalization rates, along with reduced cost may determine the fate of ESCO beyond 2020.  If CMS decides ESCO will be the prevailing dialysis management model of the future, it is possible that CMS and other dialysis stakeholders will partner with practicing dialysis companies, nephrologists and investigators to examine the utility of more innovative models of transition to dialysis that are more gradual, such as incremental dialysis whereby initial treatment may be once or twice treatments a week and dialysis frequency increases gradually over time. If an objective of ESCO is to provide better care for less money, incremental dialysis may become an important cornerstone of ESCOs and other ACO-based integrated CKD care models.

Under ESCO, we may also see greater use of home dialysis but stagnant growth of conventional in-center hemodialysis (HD). It is important to note that 600 to 800 new dialysis centers open each year in this country. How ESCOs might impact net income of nephrologists is unclear. Under ESCO, dialysis companies may gain more leverage vis-à-vis nephrologists' payments. What matters, however, is how innovations springing from the ESCO model can improve dialysis patient experience and adherence to treatment regimens, decrease mortality and hospitalization, and preserve residual kidney function longer.

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