Primary care involvement in End Stage Renal Disease Seamless Care Organizations (ESCOs) and the quality and costs of care for patients on chronic dialysis

项目摘要 接受长期透析的终末期肾病（ESRD）患者的管理成本极高， 7%的医疗保险支出，但代表1%的人口。他们的大部分费用来自管理， 该组中高度流行的多种和严重的合并症，死亡率高出20倍 与一般人群中年龄和性别相似的患者相比。为了解决这些问题，医疗保险建立了 2015年，一个以专业为导向的责任护理组织（ACO）模型，被称为ESRD无缝护理 组织（ESCO）。ESCO由透析中心和肾病学家组成，负责 成本和质量的照顾一致的受益人，以换取潜在的共享节省。关于第一次 业绩年度节省了7500万美元。到目前为止，该计划取得了可喜的成果， 迅速扩大。然而，这些节省是如何实现的以及产生了什么影响， 对临床结果的影响。并不是所有的ESCO都实现了节约， 受益人的人均储蓄。在以下方面的表现也有很大的差异： 质量测量目标，其中许多侧重于透析护理以外的常规或预防性护理方面。 因此，这些差异可以用环境保护组织成功参与的程度来解释。 初级保健医生（PCP）在照顾他们的病人-决定留给个人的自由裁量权 组织的根据他们的经验，PCP在管理这一人群方面可能特别有效 和专业知识与协调的照顾，他们的可及性，和他们的一般更全面的看法的病人。 因此，一个企业在控制支出和改善其结盟受益人的成果方面的成功， 这取决于它增加肾病学家和PCP之间互动的能力。不管怎样，目前还不清楚 ESCO是否提供任何额外的好处，比旧的初级保健为导向的ACO设计，如医疗保险 共享储蓄计划（MSSP），其中20%的慢性透析医疗保险受益人目前获得 他们的照顾。我们提出的研究有以下三个具体目的：1）评估对 2）评估五氯苯酚增加的影响 参与对经济绩效和临床结果的影响; 3）比较成本和 与MSSP相比，慢性透析患者的护理结局与PCP参与ESCO的功能有关 助理指挥官这项工作的结果将提供重要的信息，以指导目前正在进行的改组工作， 为透析人群提供医疗保健，目标是提高所提供护理的效率和质量。

PROJECT SUMMARY End-stage renal disease (ESRD) patients on chronic dialysis are extremely costly to manage, accounting for 7% of Medicare spending, yet representing 1% of the population. Most of their costs stem from management of the multiple and severe comorbidities that are highly prevalent in this group, with mortality rates 20-fold higher than patients of similar age and sex in the general population. To address these issues, Medicare established in 2015 a model of specialty-oriented accountable care organizations (ACOs), known as ESRD Seamless Care Organizations (ESCOs). Constituted by dialysis centers and nephrologists, ESCOs accept responsibility for costs and quality of care of aligned beneficiaries in exchange for potential shared savings. A report on the first performance year demonstrated $75 million in savings. With promising results to date, the program is being rapidly expanded. However, much remains unclear about how these savings were achieved and what impact they will have on clinical outcomes. Not all the ESCOs achieved savings, and there was over six-fold variation in savings per beneficiary across those that did. There was also substantial variability in performance on quality measure targets, many of which focused on aspects of routine or preventive care beyond dialysis care. These variations may, therefore, be plausibly explained by the extent to which ESCOs successfully involve primary care physicians (PCPs) in the care of their patients–a decision left to the discretion of individual organizations. PCPs may be particularly effective in the management of this population, given their experience and expertise with coordination of care, their accessibility, and their generally more holistic view of the patient. Thus, an ESCO’s success at curbing spending and improving outcomes for its aligned beneficiaries may depend on its ability to increase interactions between nephrologists and PCPs. Regardless, it remains unclear whether ESCOs offer any added benefit over older primary care-oriented ACO designs like the Medicare Shared Savings Program (MSSP), in which 20% of Medicare beneficiaries on chronic dialysis currently receive their care. We propose a study with the following three Specific Aims: 1) To assess ESCO effects on interactions among nephrologists and PCPs or other specialists 2) To assess the impact that increased PCP involvement has on ESCO financial performance and clinical outcomes and 3) To compare the costs and outcomes of care for chronic dialysis patients as a function of PCP involvement in ESCOs, versus MSSP ACOs. Findings from this work will provide critical information to guide ongoing efforts at reorganization of health care for the dialysis population with the goal of improving the efficiency and quality of care delivered.