American Journal of Kidney Diseases

Accountable Care Organizations and ESRD: The Time Has Come

Published:March 29, 2012DOI:
      Accountable care organizations (ACOs) are a newly proposed vehicle for improving or maintaining high-quality patient care while controlling costs. They are meant to achieve the goals of the Medicare Shared Savings Program mandated by the Patient Protection and Affordable Care Act (PPACA) of 2010. ACOs are voluntary groups of hospitals, physicians, and health care teams that provide care for a defined group of Medicare beneficiaries and assume responsibility for providing high-quality care through defined quality measures at a cost below what would have been expected. If an ACO succeeds in achieving both the quality measures and reduced costs, the ACO will share in Medicare's cost savings. Health care for patients with end-stage renal disease is complex due to multiple patient comorbid conditions, expensive, and often poorly coordinated. Due to the unique needs of patients with end-stage renal disease receiving dialysis, ACOs may be unable to provide the highly specialized quality care these patients require. We discuss the benefits and risks of a renal-focused ACO for dialysis patients, as well as the kidney community's prior experience with an ACO-like demonstration project.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Kidney Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Brown E.A.
        Can quality of life be improved for the increasing numbers of older patients with end-stage kidney disease?.
        Expert Rev Pharmacoecon Outcomes Res. 2010; 10: 661-666
        • Fried L.F.
        • Shlipak M.G.
        • Crump C.
        • et al.
        Renal insufficiency as a predictor of cardiovascular outcomes and mortality in elderly individuals.
        J Am Coll Cardiol. 2003; 41: 1364-1372
        • Rifkin D.E.
        • Shlipak M.G.
        • Katz R.
        • et al.
        Rapid kidney function decline and mortality risk in older adults.
        Arch Intern Med. 2008; 168: 2212-2218
        • Yarlas A.S.
        • White M.K.
        • Yang M.
        • Saris-Baglama R.N.
        • Bech P.G.
        • Christensen T.
        Measuring the health status burden in hemodialysis patients using the SF-36(R) health survey.
        Qual Life Res. 2011; 20: 383-389
        • Chiu Y.W.
        • Teitelbaum I.
        • Misra M.
        • de Leon E.M.
        • Adzize T.
        • Mehrotra R.
        Pill burden, adherence, hyperphosphatemia, and quality of life in maintenance dialysis patients.
        Clin J Am Soc Nephrol. 2009; 4: 1089-1096
        • US Renal Data System
        USRDS 2011 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Vol 2. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2011: e208 (e282)
        • St Peter W.L.
        • Khan S.S.
        • Ebben J.P.
        • Pereira B.J.
        • Collins A.J.
        Chronic kidney disease: the distribution of health care dollars.
        Kidney Int. 2004; 66: 313-321
        • Astor B.C.
        • Eustace J.A.
        • Powe N.R.
        • et al.
        Timing of nephrologist referral and arteriovenous access use: the CHOICE Study.
        Am J Kidney Dis. 2001; 38: 494-501
        • Stack A.G.
        Impact of timing of nephrology referral and pre-ESRD care on mortality risk among new ESRD patients in the United States.
        Am J Kidney Dis. 2003; 41: 310-318
        • Ortega T.
        • Ortega F.
        • Diaz-Corte C.
        • Rebollo P.
        • Ma Baltar J.
        • Alvarez-Grande J.
        The timely construction of arteriovenous fistulae: a key to reducing morbidity and mortality and to improving cost management.
        Nephrol Dial Transplant. 2005; 20: 598-603
        • Arbor Research Collaborative for Health
        End-Stage Renal Disease (ESRD) Disease Management Demonstration Evaluation Report: Findings From 2006-2008, the First Three Years of a Five-Year Demonstration, Prepared for The Centers for Medicare & Medicaid Services.
        • Nissenson A.R.
        • Deeb T.
        • Franco E.
        • Krishnan M.
        • McMurray S.
        • Mayne T.J.
        The ESRD Demonstration Project: what it accomplished.
        Nephrol News Issues. 2011; 25: 39-41
        • Sauer P.F.
        • Farrell R.E.
        • Lazarus J.M.
        The ESRD Demonstration Project: what it accomplished.
        Nephrol News Issues. 2011; 25 (34-35, 37-38): 32
        • Berwick D.M.
        Making good on ACOs' promise—the final rule for the Medicare shared savings program.
        N Engl J Med. 2011; 365: 1753-1756
      1. HR 4872, Health Care and Education Affordability Reconciliation Act, enacted March 29, 2010:5.

        • American Hospital Association, 2010 Committee on Research
        AHA Research Synthesis Report: Accountable Care Organizations.
        American Hospital Association, Chicago, ILJune 2010
      2. HR 3590, Patient Protection and Affordable Care Act. Enacted March 22, 2010.

        • US Census Bureau
        Highlights: 2009.
        (Accessed July 27, 2011)
      3. Compilation of the Social Security Laws.
        • Centers for Medicare & Medicaid Services
        Fistula First Breakthrough 2011.
        (Accessed October 15, 2011)
        • Centers for Medicare & Medicaid Services
        Medicare coverage of kidney dialysis and kidney transplant services.
        in: 2011: 12 (Accessed October 13, 2011)
      4. HR 6331, The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), enacted on July 15, 2008.

        • Centers for Medicare & Medicaid Services
        End-stage renal disease prospective payment system.
        Fed Regist. 2010; 75: 49029-49214
        • Mayne T.J.
        • Burgess M.
        • Weldon J.
        Finding the case mix adjusters in the CMS proposed bundle.
        Nephrol News Issues. 2009; 10: 34-38
        • Nissenson A.R.
        • Mayne T.J.
        • Krishnan M.
        The 2009 proposed rule for prospective ESRD payment: perspectives from a large dialysis organization.
        Am J Kidney Dis. 2010; 55: 223-226
        • Centers for Medicare & Medicaid Services
        End-Stage Renal Disease Prospective Payment System and Quality Incentive Program .
        Fed Regist. 2011; 76 (Accessed December 10, 2011): 70228-70318
        • Tollen L.A.
        Physician Organization in Relation to Quality and Efficiency of Care: A Synthesis of Recent Literature.
        (Commonwealth Fund pub. no. 1121) The Commonwealth Fund, New York, NYApril 2008
        • Centers for Medicare & Medicaid Services Medicare Program
        Medicare shared savings program: accountable care organizations.
        Fed Regist. 2011; 76: 67802-67990
        • Cauchi R.
        State legislation opposing certain health reforms, 2009-2010, National Conference of State Legislatures.
        (Accessed October 10, 2011)
        • McClellan M.
        • McKethan A.N.
        • Lewis J.L.
        • Roski J.
        • Fisher E.S.
        A national strategy to put accountable care into practice.
        Health Aff (Millwood). 2010; 29: 982-990
        • Rosenthal M.B.
        • Cutler D.M.
        • Feder J.
        The ACO rules—striking the balance between participation and transformative potential.
        N Engl J Med. 2011; 365: e6
        • Wilensky G.R.
        Lessons from the physician group practice demonstration—a sobering reflection.
        N Engl J Med. 2011; 365: 1659-1661
        • Centers for Medicare and Medicaid Services
        Fact sheet: Medicare Physician Group Practice Demonstration: physicians groups continue to improve quality and generate savings under Medicare physician pay for performance demonstration.
        (Accessed September 15, 2011)
        • Newman D.
        Accountable Care Organizations and the Medicare Shared Savings Program, Congressional Research Service, CRS Report for Congress 7-5700, R41474.
        • Lorenzo V.
        • Martn M.
        • Rufino M.
        • Hernandez D.
        • Torres A.
        • Ayus J.C.
        Predialysis nephrologic care and a functioning arteriovenous fistula at entry are associated with better survival in incident hemodialysis patients: an observational cohort study.
        Am J Kidney Dis. 2004; 43: 999-1007
        • Mendelssohn D.C.
        • Malmberg C.
        • Hamandi B.
        An integrated review of “unplanned” dialysis initiation: reframing the terminology to “suboptimal” initiation.
        BMC Nephrol. 2009; 10: 22
        • Wasse H.
        • Kutner N.
        • Zhang R.
        • Huang Y.
        Association of initial hemodialysis vascular access with patient-reported health status and quality of life.
        Clin J Am Soc Nephrol. 2007; 2: 708-714
        • Wingard R.L.
        • Pupim L.B.
        • Krishnan M.
        • Shintani A.
        • Ikizler T.A.
        • Hakim R.M.
        Early intervention improves mortality and hospitalization rates in incident hemodialysis patients: RightStart program.
        Clin J Am Soc Nephrol. 2007; 2: 1170-1175
        • Robertson J.
        • Chen G.
        • Goel P.
        • Levine R.
        • Benner D.
        Effect of IMPACT Program on Clinical Indicators of Incident Hemodialysis Patients.
        European Renal Association-European Dialysis and Transplant Association, Munich, Germany2010
        • Manley H.J.
        • Cannella C.A.
        • Bailie G.R.
        • St Peter W.L.
        Medication-related problems in ambulatory hemodialysis patients: a pooled analysis.
        Am J Kidney Dis. 2005; 46: 669-680
        • US Renal Data System
        USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Vol 2. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2010: s269-s280
        • Centers for Medicare & Medicaid Services
        [CMS 5003-N] RIN 0938-ZA39 Medicare Program; Demonstration: End-Stage Renal Disease-Disease Management.
        Fed Regist. 2003; 68 (notice): 33495
        • Coughlin J.
        • Pope J.
        • Leedle B.
        Old age, new technology and future innovations in disease management and home health care.
        Home Health Care Manage Pract. 2006; 18: 196-207
        • Rastogi A.
        • Linden A.
        • Nissenson A.R.
        Disease management in chronic kidney disease.
        Adv Chronic Kidney Dis. Jan 2008; 15: 19-28