The Department of Health and Human Services and the Centers for Medicare & Medicaid Services on July 10 announced the agency’s plan to rework payment for kidney care, including for dialysis. A press release posted to CMS’s website began, “Today, delivering on President Trump’s Advancing American Kidney Health Executive Order, the U.S. Department of Health and Human Services (HHS) Secretary Alex Azar and Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma announced five new CMS Center for Medicare and Medicaid Innovation payment models that aim to transform kidney care so that patients with chronic kidney disease have access to high quality, coordinated care. The proposed required End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model would encourage greater use of home dialysis and kidney transplants for Medicare beneficiaries with ESRD in order to preserve or enhance their quality of care while reducing Medicare expenditures, and the Kidney Care First (KCF) and Comprehensive Kidney Care Contracting (CKCC) Models will test new Medicare payment options that aim to improve the quality of care for patients kidney disease.”
A statement by HHS Secretary Alex Azar noted that, “Decades of paying for sickness and procedures in kidney care, rather than paying for health and outcomes, has produced less-than-satisfactory outcomes at tremendous cost. Through new payment models and many other actions under this initiative, the Trump Administration will transform this situation and deliver Americans better kidney health, more kidney treatment options, and more transplants.”
As the press release stated, “The current Medicare payment system encourages in-center hemodialysis as the default treatment for patients beginning dialysis. According to the Government Accountability Office, in-center hemodialysis is the most common type of dialysis and was used by about 88 percent of dialysis patients in 2016. There are more than 430,000 Medicare Fee-for-Service beneficiaries with ESRD who spend an average of 12 hours a week receiving in-center hemodialysis. Many beneficiaries with ESRD suffer from poorer health outcomes, such as higher hospitalization and mortality rates, often the result of underlying disease complications and multiple co-morbidities.
“The way we currently pay for chronic kidney disease and kidney failure isn’t working well for patients,” said CMS Administrator Seema Verma in a statement in the press release. “Under President Trump’s leadership, we are focused on strengthening Medicare and protecting the program for the individuals it was intended to serve. These historic initiatives aim to improve the quality of life for kidney disease patients by preventing disease progression, encouraging transplants over dialysis, and if dialysis is needed, more convenient home based dialysis to improve health outcomes.”
The proposed ETC Model would adjust certain Medicare payments to ESRD facilities and clinicians managing ESRD beneficiaries (Managing Clinicians) that are selected for participation in the model, through upward or downward payment adjustments based on their home and transplant rates to increase utilization of home dialysis and rates of kidney and kidney-pancreas transplants.
One of the goals of the proposed ETC model is to give ESRD beneficiaries the freedom and choice of ESRD treatment that best works with their lifestyles. For example, if a beneficiary chooses home dialysis, they would have greater flexibility to adjust the hours and frequency of their treatment. Under the proposed ETC Model, CMS would make certain payment adjustments that would encourage participating ESRD facilities and Managing Clinicians to ensure that ESRD beneficiaries have access to and receive education about their kidney disease treatment options. Specifically, CMS would positively adjust certain Medicare payments to participating ESRD facilities and Managing Clinicians for the first three years of the model for home dialysis and dialysis-related services.
A fact sheet posted to the CMS website included several questions and answers, among them: “Why develop a model for home dialysis and transplantation? Both of these modalities, home dialysis and transplantation, seem to have support among health care providers and patients as preferable alternatives to in-center hemodialysis, but utilization has been less than in other developed nations. For example, studies have shown that for patients who require dialysis, dialyzing at home is often preferred by patients and physicians. The benefits include increased independence and quality of life. The rate of home dialysis in the U.S. – about 12% in 2016 – falls far below that of other developed nations. In addition, kidney is widely viewed as the optimal treatment for most patients with ESRD, generally increasing survival and quality of life while reducing medical expenditures. However, in 2016 only 29.6% of prevalent ESRD patients in the U.S. had a functioning transplant and only 2.8% of incident patients received a preemptive transplant.[3] These rates are below those of other developed nations. The U.S. was ranked 39th of 61 countries reporting USRDS in kidney transplants per 1,000 dialysis patients in 2016.” And also this: “What is the proposed model timeline? The payment adjustments for those ESRD facilities and Managing Clinicians selected for participation in the proposed ETC model would apply to applicable Medicare claims with dates from January 1, 2020 through June 30, 2026.”
