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

项目总结 接受慢性透析的终末期肾病(ESRD)患者的管理成本极其高昂，占 占医疗保险支出的7%，但占人口的1%。他们的大部分成本来自于管理 在这一群体中非常普遍的多种严重并存，死亡率高出20倍 比一般人群中年龄和性别相近的患者更多。为了解决这些问题，联邦医疗保险建立了 2015年，一种以专业为导向的责任护理组织(ACO)的模式，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 统一受益人的成本和护理质量，以换取潜在的共享节省。一篇关于一号的报道 业绩年度节省了7500万美元。到目前为止，该项目取得了令人振奋的成果， 迅速扩张。然而，这些节省是如何实现的，以及产生了什么影响，目前仍不清楚 他们将对临床结果产生影响。并不是所有的ESCO都实现了节省，而且有超过6倍的变化 在那些这样做的人中，每个受益人的储蓄。在性能上也有很大的变异性 质量衡量目标，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，这些差异可以通过ESCO成功参与的程度来合理解释 护理病人的初级保健医生(PCP)--这是一个由个人自行决定的决定 组织。考虑到初级保健医生的经验，他们在管理这一人群方面可能特别有效 和专业知识，协调护理，他们的可获得性，以及他们通常对患者更全面的看法。 因此，ESCO在控制支出和改善其一致受益者的成果方面的成功可能 这取决于它是否有能力增加肾病学家和初级保健医生之间的互动。无论如何，目前仍不清楚 ESCO是否提供比旧的以初级保健为导向的ACO设计(如Medicare)更多的好处 共享储蓄计划(MSSP)，其中20%的慢性透析联邦医疗保险受益人目前获得 他们的关心。我们建议进行以下三个具体目标的研究：1)评估ESCO对 肾病学家和初级保健医生或其他专家之间的互动2)评估初级保健医生增加初级保健医生的影响 参与对ESCO的财务业绩和临床结果有影响；3)比较成本和 与MSSP相比，慢性透析患者的护理结果与ESCO中PCP的参与有关 司令官。这项工作的发现将为指导正在进行的重组工作提供关键信息 为透析人群提供保健服务，目的是提高提供保健服务的效率和质量。

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.