The American Kidney Fund comments on ESRD model on home dialysis and transplant

The American Kidney Fund (AKF) submitted a comment letter to the Centers for Medicare & Medicaid Services (CMS) regarding their proposed rule on the End-Stage Renal Disease (ESRD) Treatment Choices Model (ETC model). In our letter, we voiced support for the objectives of the ETC model:

  • test the effectiveness of adjusting Medicare payments to providers to encourage greater use of home dialysis and kidney transplantation
  • support beneficiary modality choice
  • reduce Medicare spending, and
  • preserve or enhance the quality of care.

However, we also raised concerns with certain aspects of the ETC model and made recommendations to better ensure patient choice and quality of care, increase patient education, and better measure the patient experience.

As part of the U.S. Department of Health and Human Services’ Advancing American Kidney Health initiative, the ETC model is a proposed mandatory payment model for ESRD facilities and managing clinicians in selected geographic areas. The timeline for the model would be January 1, 2020 through June 30, 2026. Participating providers would see certain upward or downward adjustments to their Medicare payments based on their home dialysis rate and transplant rate performance.

While AKF commended CMS and HHS for launching the kidney initiative, voiced support for the objectives of the ETC model, and expressed support for certain proposed provisions, we also made the following recommendations:

  • To ensure true patient choice in their treatment options, we recommend that CMS allow for the exclusion from the payment adjustment measures patients who, after appropriate patient education, decide not to proceed with home dialysis, as well as patients who may not be suitable candidates for home dialysis or transplantation for clinical reasons. Allowing this exclusion would better account for socioeconomic and clinical factors that play a critical role in modality choice.
  • CMS should expedite its current development and testing of transplant referral measures and obtain National Quality Forum (NQF) endorsement so that it can be used in the ETC model. AKF supports the use of meaningful transplant measures that are actionable by facilities and clinicians, and the use of an NQF-endorsed referral measure would be a more appropriate metric, since increasing the number of transplants that occur also depends on the actions of other stakeholders—actions that are not addressed in the ETC model.
  • While AKF greatly appreciates CMS’ proposals that would waive some requirements that currently limit the use of the Medicare Kidney Disease Education (KDE) benefit, we recommend that CMS also waive the beneficiary coinsurance requirement for KDE benefits, expand the number of beneficiaries who can receive the benefit via telehealth, and permit ESRD facilities to provide the KDE benefit to certain patients. Given the importance of patient education in empowering beneficiaries to make the right choice for them, CMS should incorporate these additional changes to further expand the use of the KDE benefit.
  • CMS should work with stakeholders to develop a Consumer Assessment of Healthcare Providers and Systems Survey and Experience of Care (CAHPS) survey for home dialysis patients, so that it can be used in the ETC model to formally measure the patient experience.

Posted: | Author: Michael Ly, Director Of Public Policy - American Kidney Fund