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More time is needed to make ESRD Treatment Choices model workable
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Under the mandatory ESRD Treatment Choices proposal, HHS and CMS propose incentives and penalties to dialysis facilities to encourage greater use of home dialysis and transplantation. CMS intends to assign half of the dialysis facilities in the United States to one of two groups based on hospital referral regions. One group which serves as the control would continue to do business as usual, and the facilities in the study group would be subject to incentives and penalties to attain certain benchmarks on the number of patients moving to home dialysis or receiving kidney transplants. The facilities in the study group that fail to achieve the benchmark would sustain penalties as high as 13% for all of their in-center dialysis treatments.
This is not a voluntary model and neither the patients nor the facilities have the right to opt out in the study group or opt in to the control group. CMS wants to implement this plan as early as Jan. 1.
The proposed model has all the attributes of a “mega” clinical trial in population health without required safeguards to prevent real or perceived harm to subjects, usurping their right to refuse to participate. Its main objective is to find out whether incentives and penalties would change the behavior of nephrologists and dialysis facilities to increase home dialysis and kidney transplants and reduce Medicare expenditures.
If the administration would like to move forward, I suggest a smaller scale trial with 6% to 10% of the current dialysis population during a period of 5 years to obtain statistical strength.
The challenge, of course, is that that these two agencies must act and implement quickly; Advancing American Kidney Health, signed as an executive order by President Donald J. Trump on July 10, sets goals within the next 6 to 10 years to alter the path of kidney disease. That means change must come quickly. CMS overestimates our readiness to implement this program in such short notice. We would need a large cadre of properly trained and willing nephrologists and nurses “shovel ready” within the next 90 to 180 days.
Limitations of modality change
In general, home dialysis is not just about making a simple change of venue to where the treatments take place. Home dialysis is a full-time proposition for the nephrologists and the support staff. There are other issues, too, such as the following:
- If more patients are expected to go home for dialysis, incentives for the nephrologists should be aligned with the increased burden placed on them. The ESRD Treatment Choice (ETC) model offers a 3% increase in the nephrologist monthly capitation payment in the first year the patient is on home therapy, but that drops to 1% by the third year and then disappears altogether.
- Many patients who are otherwise suitable for home modality are reluctant to place additional burden on their family to help them. The current reimbursement structure for dialysis under Medicare does not allow us to provide staff-assisted home dialysis. In my view, this is one of the major factors that would limit the number of patients interested in home therapy.
- Inadequate housing is a barrier for home dialysis for patients who live in the inner cities where there is a concentration of patients with ESRD. Storage space for dialysis equipment and supplies is a major challenge.
- A demographic shift in the patient population during the last decade means more patients starting dialysis are elderly, disabled and may be otherwise unsuitable for home modality. That makes attaining the ETC benchmarks difficult.
Despite the shortcomings, in-center hemodialysis provides a “social outlet” for patients with kidney disease. Many patients complain of social isolation after starting dialysis. Due to their dietary restrictions and lack of free time, they lose the circle of friends they had prior to starting dialysis.
More harm than good
I laud the administration for focusing on kidney health as a priority, but I believe HHS and CMS have an unrealistic expectation that the nephrology community would be ready for this push toward the mandatory ETC model in such short notice. Without careful consideration of the input from the kidney care community, it may lead to serious harm and jeopardize the relationship between patients and their care providers.
- For more information:
- J.G. Bhat, MD, is the co-principal of Atlantic Dialysis LLC, based in New York.
Disclosure: Bhat reports he has no relevant financial disclosures.