COMPREHENSIVE ESRD CARE MODEL
Overview
On January 31, 2013, the Centers for Medicare & Medicaid Services (CMS) released a call for applications to participate in the testing of the new Comprehensive End-Stage Renal Disease (ESRD) Care model. Through this new initiative, CMS will partner with groups of health care providers and suppliers – ESRD Seamless Care Organizations (ESCOs) - to test and evaluate a new model of payment and care delivery specific to Medicare beneficiaries with ESRD. The goals of the Model are to improve beneficiary health outcomes and reduce per capita Medicare expenditures.
Background
Improving Care for Beneficiaries with ESRD
Beneficiaries with ESRD have significant care needs. In 2010, beneficiaries with ESRD constituted 1.3% of the Medicare population and accounted for an estimated 7.5% of total Medicare spending, totaling over $20 billion. These high costs are often the result of underlying disease complications and multiple co-morbidities, which often lead to high rates of hospital admission and readmissions, as well as a mortality rate that is much higher than the general Medicare population.
Because of these complex health needs, beneficiaries often require to visit multiple providers and follow multiple care plans, which can be challenging for beneficiaries if care is not coordinated. Through enhanced care coordination, these beneficiaries will have a more patient-centered care experience, which will ultimately, improve health outcomes.
The Innovation Center
The Innovation Center was created by the Affordable Care Act to test innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care. The Innovation Center evaluates models of payment and service delivery for their effectiveness in improving the care offered to beneficiaries of Medicare, Medicaid, and the Children’s Health Insurance Program; improve the health of those beneficiaries; and lower expenditures to those programs.
The Comprehensive ESRD Care model – Improving Care for a Unique Population
CMS established the Comprehensive ESRD Care model to test a new system of payment and care delivery that will lead to better health outcomes for Medicare beneficiaries living with ESRD, while lowering costs to Medicare Parts A and B. Under the model, CMS will work with groups of health care providers and suppliers involved in the care of ESRD beneficiaries to improve the coordination and quality of care that these individuals receive.
Participating Organizations – Improved Care Through Collaboration
Participating organizations will consist of groups of health care providers led by care professionals experienced in providing care to beneficiaries with ESRD. The organizations must include representation from dialysis facilities, nephrologists, and other Medicare providers and suppliers.
To be eligible, ESCOs must have a minimum of 500 beneficiaries “matched” to their organization. The matching process will use historical data on beneficiaries who are receiving care from participating providers.
Payment Arrangement – Rewarding High Quality Care
Participating organizations will be clinically and financially responsible for all care offered to a group of matched beneficiaries, not only dialysis care or care specifically related to a beneficiary’s ESRD. Using a robust set of quality measures that assesses both the health and experience of beneficiaries with ESRD receiving care from providers and suppliers participating in the model, CMS will assess the performance of the organizations in improving beneficiary outcomes. ESCOs that succeed in offering high quality care that lowers the total Parts A and B cost of care for those beneficiaries will have the opportunity to share in Medicare savings with CMS.
The model offers three payment tracks, depending on the size of the dialysis facility participating in the model. ESCOs that include at least one dialysis facility owned by a large dialysis organization (an organization with more than 200 dialysis facilities) must participate in a risk-based payment arrangement over the life of the model. Other participating organizations may join in one of two other payment tracks.
Beneficiary Protections
The principal goal of the model is to provide beneficiaries with ESRD an improved care experience. To ensure beneficiaries receive this high quality care, CMS has developed a model that puts beneficiaries at the center of their care:
- Putting the Patient First – The model creates new incentives for providers to work together to improve the care beneficiaries receive.
- Beneficiary Choice – Beneficiaries matched to an ESCO will maintain all the rights and benefits of beneficiaries in Medicare fee-for-service, including the freedom to see any health care provider who accepts Medicare.
- Active Monitoring – CMS will closely and routinely analyze data assessing the utilization of services of these beneficiaries. This monitoring will occur through the use of audits and other actions as necessary. Beneficiaries will be surveyed each year to assess their experience with the new initiative.
Beneficiaries can contact CMS to ask questions and relay any concerns. ESCOs will send a notice to beneficiaries that will inform them that they can call 1-800 MEDICARE at any time to ask questions about the program, and alert CMS of any concerns they may have about the participating organization.
Governance Structure – Giving Beneficiaries a Seat at the Table
CMS believes it is important that patients and their advocates be meaningful partners in improving care delivery. ESCOs will include both a patient representative and a consumer advocate on their governing body. Through this representation, CMS will ensure that the beneficiary and consumer representatives participate in all strategic decisions made by the organizations.
Quality Measures
Under the Comprehensive ESRD Care model, participating organizations will be held financially accountable for delivering high quality care and improving the health outcomes of their matched beneficiaries. Participating ESCOs will be required to report on a variety of care delivery and health outcome measures across the continuum of care, not only for ESRD services.
The quality measures will fall under five areas:
- Preventative Health
- Chronic Disease Management
- Care Coordination and Patient Safety
- Patient and Caregiver Experience
- Patient Quality of Life
ESCOs that do not achieve a high standard of quality will be ineligible to share in savings generated from the model, and may also be terminated from participation.
Application Process
Organizations interested in participating in the testing of the model are required to submit both a letter of intent and an application to CMS. Letters of intent are nonbinding, but are a required prerequisite to submitting an application to CMS.
Interested applicants are required to submit non-binding letters of intent, which are due March 15, 2013. Applications are due May 1, 2013.
Information about how to apply is available on the Innovation Center website at http://innovation.cms.gov/initiatives/comprehensive-ESRD-care/.