ACOs reduce costs for patients with ESKD
Accountable care organizations generated modest savings in the care of Medicare beneficiaries undergoing dialysis when patients received routine care from primary care physicians.
“Representing only 1% of the population, beneficiaries with kidney failure on long-term dialysis nonetheless account for more than 7% of Medicare’s traditional fee-for-service spending,” Vahakn B. Shahinian, MD, MS, and colleagues from the University of Michigan Ann Arbor wrote. “Notably, only a minority of these costs are directly attributable to provision of dialysis and dialysis-related drugs ... Instead, most of the expense of this population stems from the management of a constellation of comorbidities (eg, diabetes mellitus, heart failure) and associated complications afflicting the typical long-term dialysis patient.
“While the costs of dialysis and dialysis-related drugs are relatively fixed, those related to management of comorbidities are more variable, and potentially amenable to efforts at cost containment,” the researchers wrote.
The ACOs involved in the care of patients on dialysis in the study were part of the Medicare Sharing Savings Program and in operation before 2017. Care in such programs was directed by PCPs.
“It is unclear ... whether ACOs would be an appropriate model of care for long-term dialysis beneficiaries,” the authors wrote. “On one hand, ACOs may be an effective model given their focus on coordinated care, which would be expected to be applicable to long-term dialysis beneficiaries who often have multiple comorbidities for which they are frequently hospitalized.”
They added, “On the other hand, PCPs may lack specialized knowledge and experience in caring for the medical issues of long-term dialysis beneficiaries or may duplicate care provided by nephrologists who already necessarily follow such beneficiaries regularly. This may result in care inefficiencies, potentially leading to increased spending.”
The researchers analyzed national Medicare claims data from a 20% random sample of beneficiaries who received dialysis before 2017. During the study, 135,152 patients on dialysis were identified. Cost analysis was based on spending on Medicare Part A and Part B patient services.
During the study period from 2012 to 2016, the percent of long-term patients on dialysis who were assigned to an ACO increased from 6% to 23%.
“In the time series analysis, spending on ACO-aligned beneficiaries was $143 (95% CI $5 to $282) less per beneficiary-quarter than spending for non-aligned beneficiaries,” the researchers wrote. “In analyses stratified by whether beneficiaries received care by a [PCP], savings by ACO-aligned beneficiaries were limited to those with care by a PCP ($235, 95% CI $73 to $397).”
The savings produced by the ACOs were “relatively modest,” the researchers acknowledged. “There are newer programs directed specifically at this group of patients, including the End-Stage Renal Disease Seamless Care Organization, or ESCO, program started in October 2015 and the upcoming Advancing American Kidney Health initiative,” Shahinian and colleagues said in a press release summarizing the study. “Our study looked at an older and more general program, the Medicare Shared Savings Program ACOs, which started in 2012 and were directed to the Medicare population in general. In future work, it will be of interest to see if the newer, more kidney disease-specific programs will do even better than the ACO programs were able to achieve.”
In an accompanying editorial, authors Ahmed Awan, MD, and Kevin F. Erickson, MD, MS, agreed that the potential for savings would improve with newer payment models released during the last decade, noting “one reason why savings among ACO beneficiaries receiving long-term dialysis are small — or nonexistent — may be because many ACOs do not focus specifically on patients with end-stage kidney disease ... health care providers participating in ACOs will need to identify ways to incorporate ESKD care in their broader chronic care management programs.”
Awan A, et al. Clin Jrnl Am Soc Neph. 2020;doi:10.2215/CJN.16521020
Bakre S, et al. Clin Jrnl Am Soc Neph. 2020;doi:10.2215/CJN.02150220