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Abstract: FR-OR22

Organizational Characteristics Associated with High Performance in Medicare's ESRD Seamless Care Organizations

Session Information

Category: Dialysis

  • 701 Dialysis: Hemodialysis and Frequent Dialysis


  • Drewry, Kelsey M., Emory University, Atlanta, Georgia, United States
  • Trivedi, Amal, Brown University, Providence, Rhode Island, United States
  • Wilk, Adam S., Emory University, Atlanta, Georgia, United States

In 2016, the 1% of beneficiaries with end-stage renal disease (ESRD) constituted >7% of Medicare spending ($35 billion). To improve the value of care for the ESRD population, CMS implemented an alternative payment model (APM) for ESRD care, the ESRD Seamless Care Organization (ESCO), which shares savings with provider groups that reduce spending for ESRD patients below a defined benchmark. This study evaluated the relationship between key organizational, provider, community characteristics, and ESCO performance.


We constructed a novel ESCO-level dataset capturing key information for Wave 2 (2017) ESCOs using data from CMS reports, the National Provider Identification registry, and the Area Health Resource File. After describing all 37 ESCOs, we performed bivariate comparisons of high- and low-performing (above vs below median) ESCOs based on gross savings/losses, composite quality score, and standardized mortality ratio (SMR). We then estimated generalized logistic regression models of ESCO performance as a function of organizational, provider, and community characteristics.


ESCO composition and performance were highly varied (ranges: savings/losses -3.9-10.2%; quality 76.4-100%; SMR 0.75-1.14). Bivariate analysis showed that ESCOs with above (vs below) median savings had more aligned physicians (58 vs 29, p=0.06), fewer dialysis facilities (8.7 vs 17, p=0.07), a smaller non-Hispanic Black population (14% vs 22%, p=0.06), and higher median household income ($56k vs $49k, p<0.01). Facilities reporting a quality score of 100% (vs <100%) had fewer practices (22 vs 43, p=0.05) and smaller non-Hispanic Black (16% vs 21%, p=0.06) and Medicaid eligible (6.5% vs 8.9%, p=0.14) populations. Low (vs above-median) SMR was associated with higher median household income ($58k vs $46k, p<0.01). Regression model results were consistent with these findings, though small sample size prevented statistically significant estimates.


Our findings offer the first evidence of the impact of organizational composition and social disparities on ESCO performance. We show that the diversity in ESCOs' composition and settings partially explained the high variation in performance. This study provides crucial evidence that will inform the design and implementation of APMs in nephrology and the decisions of provider groups considering participation.