The announcement of the Advancing American Kidney Health (AAKH) Initiative on July 10, 2019 was met with a mix of excitement and trepidation, befitting a proposed radical reconfiguration of the delivery of kidney disease care. Aspiring to reduce the incidence of end‐stage renal disease, increase the prevalence of home dialysis, and double the number of organs available for transplant, the AAKH payment models primarily focus on incenting behaviors of general nephrologists, though actualizing positive incentives will require the active cooperation of dialysis providers and transplant centers. Here, we review the AAKH initiatives’ potential impact on all stakeholders and opine on financial and regulatory pressures on kidney transplant programs, outlining areas of uncertainty and concern, and suggest key points of reflection for clinical and administrative leaders of kidney transplant centers weighing participation in any of the voluntary payment models.

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This study uniquely demonstrates the trajectories of key parameters though the transition from pre-dialysis to post-dialysis start. Significant differences are noted in the pre-dialysis period for patients who survive vs. those who do not survive the first year of dialysis. Early recognition of adverse trends in the pre-dialysis period may create opportunity to intervene to improve early dialysis outcomes.

As the prevalence of chronic kidney disease is expected to rise worldwide over the next decades, provision of renal replacement therapy (RRT), will further challenge budgets of all healthcare systems. Most patients today requiring RRT are treated with haemodialysis (HD) therapy and are elderly. This article demonstrates the interdependence of clinical and sustainability criteria that need to be considered to prepare for the future challenges of delivering dialysis to all patients in need. Newer, more sustainable models of high-value care need to be devised, whereby delivery of dialysis is based on value-based healthcare (VBHC) principles, i.e. improving patient outcomes while restricting costs. Essentially, this entails maximizing patient outcomes per amount of money spent or available. To bring such a meaningful change, revised strategies having the involvement of multiple stakeholders (i.e. patients, providers, payers and policymakers) need to be adopted. Although each stakeholder has a vested interest in the value agenda often with conflicting expectations and motivations (or motives) between each other, progress is only achieved if the multiple blocs of the delivery system are advanced as mutually reinforcing entities. Clinical considerations of delivery of dialysis need to be based on the entire patient disease pathway and evidence-based medicine, while the non-clinical sustainability criteria entail, in addition to economics, the societal and ecological implications of HD therapy. We discuss how selection of appropriate modes and features of delivery of HD (e.g. treatment modalities and schedules, selection of consumables, product life cycle assessment) could positively impact decision-making towards value-based renal care. Although the delivery of HD therapy is multifactorial and complex, applying cost-effectiveness analyses for the different HD modalities (conventional in-centre and home HD) can support in guiding payability (balance between clinical value and costs) for health systems. For a resource intensive therapy like HD, concerted and fully integrated care strategies need to be urgently implemented to cope with the global demand and burden of HD therapy.

The Comprehensive ESRD Care (CEC) Model is designed to identify and evaluate new ways to improve care and reduce cost for Medicare beneficiaries with ESRD (1). With 24 Fresenius Medical Care North America (FMC) sites in the ESRD Seamless Care Organizations (ESCOs), we appreciate the opportunity to discuss our approach, opportunities, and challenges. This perspective aims to highlight early learnings from the ESCO program sponsored by the Center for Medicare and Medicaid Innovation (CMMI).The ESCO program shows three elements of valuebased health care on the basis of the work by Porter and Teisberg (2), namely quality of care, service delivery (including patient experience and engagement), and cost control. We believe that the ESCO program has the opportunity to lead to a payment model with long-term sustainable results. ESCOs in a NutshellAn ESCO is a partnership between a nephrology practice(s) and a dialysis organization. Medicare beneficiaries with ESRD are attributed to the ESCO on the basis of "first touch." First touch occurs when Medicare processes a claim submitted for outpatient dialysis by a dialysis clinic participating in an ESCO. The ESCO participants are responsible for the total Medicare Part A and B spending incurred by aligned beneficiaries. The CMMI establishes a historically based financial benchmark. If the cost of care for attributed beneficiaries is less than the benchmark, the ESCO participants have the opportunity to share savings with Medicare. If costs exceed the benchmark, the ESCO participants share the financial loss with Medicare. The amount of savings shared or the size of the check that the ESCO writes to Medicare is directly dependent on the ESCO's quality score. A higher score financially advantages the ESCO, whereas lower quality scores have the opposite effect. These reconciliations of the cost and clinical quality scores occur after the performance year. All ESCO participants are exposed to more than nominal financial risk.Today, there are 37 ESCOs participating in the Comprehensive ESRD Care Model. FMC partners with over 800 nephrology providers in 20 states and the District of Columbia to manage an ESCO population of patients clinically similar to the overall FMC patient population. Approach to Clinical Care within an ESCOClinical care within an ESCO assumes broad care coordination responsibility for all clinical conditions of a patient. Patients with ESRD have high resource utilization with respect to cardiac and vascular disease, infections, behavioral health, nutrition, and endocrine care. Common sites of service include ambulatory, home, emergency department, hospital, and dialysis facility. The approach taken leverages both site of service and clinical condition competence around three themes: medical management, care navigation, and financial stewardship.Medical management focuses on ESCO quality measures (3) and daily care. This uses algorithms to address dialysis treatment prescription, anemia management, and bone and mineral metabolism but also includes logistic as...