Medicare plans to extend financial structures tested through the Comprehensive End-Stage Renal Disease Care (CEC) Initiative—an alternative payment model for maintenance dialysis providers—to promote high-value care for beneficiaries with kidney failure. The End-Stage Renal Disease Seamless Care Organizations (ESCOs) that formed under the CEC Initiative varied greatly in their ability to generate cost savings and improve patient health outcomes. This study examined whether organizational or community characteristics were associated with ESCOs’ performance.

We used a retrospective pooled cross-sectional analysis of all 37 ESCOs participating in the CEC Initiative during 2015–2018 (n=87 ESCO-years). Key exposures included ESCO characteristics: number of dialysis facilities, number and types of physicians, and years of CEC Initiative experience. Outcomes of interest included were above versus below median gross financial savings (2.4%) and standardized mortality ratio (0.93). We analyzed unadjusted differences between high- and low-performing ESCOs and then used multivariable logistic regression to construct average marginal effect estimates for parameters of interest.

Above-median gross savings were obtained by 23 (52%) ESCOs with no program experience, 14 (32%) organizations with 1 year of experience, and seven (16%) organizations with 2 years of experience. The adjusted likelihoods of achieving above-median gross savings were 23 (95% confidence interval, 8 to 37) and 48 (95% confidence interval, 24 to 68) percentage points higher for ESCOs with 1 or 2 years of program experience, respectively (versus none). The adjusted likelihood of achieving above-median gross savings was 1.7 (95% confidence interval, –3 to –1) percentage points lower with each additional affiliated dialysis facility. Adjusted mortality rates were lower for ESCOs located in areas with higher socioeconomic status.

Smaller ESCOs, organizations with more experience in the CEC Initiative, and those located in more affluent areas performed better under the CEC Initiative.

Medicare 计划扩展通过综合终末期肾脏疾病护理 (CEC) 计划（维持透析提供者的替代支付模式）测试的财务结构，以促进对肾衰竭受益人的高价值护理。根据 CEC 倡议成立的终末期肾病无缝护理组织 (ESCO) 在节省成本和改善患者健康结果方面的能力差异很大。本研究调查了组织或社区特征是否与 ESCO 的绩效相关。

我们对 2015-2018 年期间参与 CEC 计划的所有 37 家 ESCO（ n = 87 ESCO 年）进行了回顾性汇总横截面分析。关键风险包括 ESCO 特征：透析设施的数量、医生的数量和类型，以及多年的 CEC 倡议经验。感兴趣的结果包括高于和低于中位数的总财务储蓄 (2.4%) 和标准化死亡率 (0.93)。我们分析了高绩效和低绩效 ESCO 之间未经调整的差异，然后使用多变量逻辑回归来构建感兴趣参数的平均边际效应估计值。

23 家 (52%) 没有项目经验的能源服务公司、14 家 (32%) 有 1 年经验的组织和 7 家 (16%) 有 2 年经验的组织获得了高于中位数的总节省。对于具有 1 年或 2 年项目经验的 ESCO，实现高于中位数总储蓄的调整后可能性分别高出 23（95% 置信区间，8 至 37）和 48（95% 置信区间，24 至 68）个百分点（与无）。每增加一个附属透析设施，调整后实现高于中位数总储蓄的可能性就会降低 1.7（95% 置信区间，–3 到 –1）个百分点。位于社会经济地位较高地区的 ESCO 的调整后死亡率较低。

规模较小的节能服务公司、在 CEC 计划中拥有更多经验的组织以及位于较富裕地区的组织在 CEC 计划下表现更好。