News Release

Characteristics associated with high performance in Medicare’s ESCO initiative to improve care for patients with kidney failure

Peer-Reviewed Publication

American Society of Nephrology


  • During 2015–2021, Medicare implemented an initiative that offered financial incentives for enhanced care coordination and patient outcomes among providers treating Medicare beneficiaries with kidney failure.
  • In this analysis, certain characteristics of participating provider groups and their communities were associated with better performance.

Washington, DC (October 7, 2021) — An analysis published in CJASN examines aspects of care for patients with kidney failure in the United States and provider financial performance following the implementation of an innovative payment model in Medicare.

Care for patients with kidney failure is disproportionately costly, and outcomes for these patients are poor. Medicare and other payers are increasing their use of value-based alternative payment models—payment systems designed to incentivize health care providers to use higher-quality, lower-cost services—as part of their efforts to improve patients’ health outcomes and slow growth in spending. Notably, Medicare has implemented payment policies that offer financial incentives for enhanced care coordination and better health and treatment outcomes for patients among providers treating Medicare beneficiaries with kidney failure, or end-stage renal disease (ESRD).

These new payment models build upon the financial incentives tested in Medicare’s first large-scale nephrology-specific alternative payment model, the Comprehensive ESRD Care Initiative, which was implemented between October 2015 and March 2021. Under the Comprehensive ESRD Care Initiative, participating provider groups, called ESRD Seamless Care Organizations (ESCOs) repaid Medicare a share of “excess” costs if total inpatient and outpatient care costs for attributed beneficiaries were above a predetermined benchmark, and ESCOs shared in Medicare’s savings if care costs fell below the benchmark, conditional on achieving a specified level of quality measure performance.

Because ESCOs varied greatly in their ability to generate cost savings and improve patient health outcomes, Kelsey M. Drewry, MA, Adam S. Wilk, PhD (Emory University Rollins School of Public Health) and their colleagues sought to determine which organizational or community characteristics might affect ESCOs’ performance.

The study included all 37 ESCOs participating in the initiative during 2015–2018. Among the major findings:

  • Above-median gross savings were obtained by 23 (52%) ESCOs with no program experience, 14 (32%) ESCOs with one year of experience, and 7 (16%) of ESCOs with two years of experience.
  • After adjustments, the likelihood of achieving above-median gross savings was 23 and 48 percentage points higher for ESCOs with one or two years of program experience (vs. none), respectively.
  • The adjusted likelihood of achieving above-median gross savings was 1.7 percentage points lower with each additional affiliated dialysis facility.
  • Adjusted mortality rates were lower for ESCOs located in areas with higher socioeconomic status.

“Together, these findings suggest that multiple different factors—leaner operations, greater organizational experience, and greater community resources among them—may contribute to successful performance and sustained provider participation in payment models that provide financial incentives for physicians to deliver higher-value care,” said Dr. Wilk. “The results will help inform healthcare providers who may be considering whether to participate in new models of physician payment, and it will help policymakers and payers working to revise existing payment models and develop new ones to achieve their system-level goals of increasing value.”

An accompanying editorial notes that the researchers’ analysis “provides additional insights into the characteristics of programs that succeed in creating shared savings in value-based kidney care.”

Study authors include Kelsey M. Drewry, MA; Amal N. Trivedi, MD, MPH; and Adam S. Wilk, PhD.

Disclosures: The authors reported no relevant financial disclosures. 

The article, titled “Organizational Characteristics Associated with High Performance in Medicare’s Comprehensive End-Stage Renal Disease Care Initiative,” will appear online at on October 7, 2021, doi: 10.2215/CJN.04020321.

The editorial, titled “Value-Based Kidney Care: A Recipe for Success,” will appear online at on October 7, 2021, doi: 10.2215/CJN.11250821.

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Since 1966, ASN has been leading the fight to prevent, treat, and cure kidney diseases throughout the world by educating health professionals and scientists, advancing research and innovation, communicating new knowledge, and advocating for the highest quality care for patients. ASN has more than 21,000 members representing 131 countries. For more information, visit

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