Changes to ESRD Treatment Choices model carry some risk for providers
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On July 18, 2019, CMS proposed ESRD Treatment Choices, a new payment model for the kidney care community aimed at increasing use of home dialysis and kidney transplantation.
The comment period closed 2 months later and, for an entire year, everyone wondered about the fate of ESRD Treatment Choices (ETC) as the agency busied itself with the COVID-19 pandemic.
Wonder no more: ETC is a “go,” effective Jan. 1, 2021. The final rule on the demonstration, which goes through 2027, was released on Sept. 18 and retains the spirit of the proposed version of the model released more than 1 year ago. Changes outlined below should be of interest to both nephrologists and dialysis providers.
Participation
Participation remains mandatory for all health care providers (dialysis facilities and nephrology practices) in Hospital Referral Regions (HRRs) that were randomly selected for inclusion by CMS starting in 2021. However, CMS lowered the percentage of HRRs participating in the model from 50% to 30%. Thus, 95 of the 306 HRRs are participating in ETC.
The complete list of participating HRRs and their constituent ZIP codes are available at https://innovation.cms.gov/innovation-models/esrd-treatment-choices-model.
Only patients with Medicare fee-for-service coverage are included in ETC. However, there are two important revisions. First, any patient with a claims-based diagnosis of dementia is excluded. Second, patients residing or dialyzing in a skilled nursing facility (SNF) are excluded; presumably, this exclusion will apply to short-term and long-term residents. In the preliminary form, SNF residents were included in the model and on-site dialysis at a SNF-constituted home dialysis.
Aggregation
All performance evaluation occurs within the boundaries of an HRR. All dialysis facilities within an HRR that are commonly owned are graded as a single unit. All “singleton” facilities are graded individually.
If a facility is owned by a national organization, but that facility is alone in its HRR, then that facility is graded individually.
For nephrology practices, the logic is the same. A practice with multiple providers collecting monthly capitated payments will be graded as a single unit. Solo providers will be graded individually. In tandem with this revision, all the attendant methodology about reliability adjustment is eliminated.
Performance measures
The Modality Performance Score (MPS) retains its original form. The MPS is calculated on a rolling basis and reflects performance during a 12-month period. The MPS sits on a 6-point scale, with 0 to 4 points reflecting home dialysis or in-facility self-care utilization and 0 to 2 points reflecting transplant wait-listing. Each part of the MPS can be influenced by absolute achievement or improvement from one measurement period to the next, although the highest possible score is achieved only through absolute achievement.
Home or self-care dialysis
Home dialysis utilization is easy to identify: A Medicare claim with a condition code of 74 (home) or 76 (in-facility backup) constitutes home dialysis. Both home hemodialysis and peritoneal dialysis qualify.
In the final form of the ETC, CMS added a code for in-facility self-care dialysis. This care model is billed with condition code 72. In 2018, there were all of 2,725 dialysis facility claims with this code.
Ultimately, the performance measure is the percentage of all dialysis patient months with either home or in-facility self-care dialysis, but with only half credit awarded to months with self-care dialysis. The performance measure is not risk-adjusted for demographic, socioeconomic or comorbid factors.
Transplant wait-listing
In the preliminary form of ETC, this performance measure was essentially equal to the transplant rate among patients receiving dialysis. That approach was canceled after some of the 300-plus comments received by CMS on the ETC indicated it was unfair for those providing dialysis care to be held responsible for the number of kidneys made available for transplant.
Instead, dialysis facilities will be evaluated according to transplant wait-listing and living donor transplants. Specifically, the performance measure, which is limited to patients aged younger than 75 years, is the percentage of dialysis patient-months with waitlisting for a transplant or receipt of a living donor transplant.
The measure is risk-adjusted, but only for three age brackets: 18 to 55 years, 56 to 70 years and 71 to 74 years. There is no adjustment for comorbid factors. For nephrology practices, the logic is the same, but the performance measure includes preemptive living donor transplants.
Finances, waivers
Most of the language here remains the same to the proposed rule. In 2021, a home dialysis payment adjustment (+3%) will be made on all claims for home dialysis. The value declines to 2% in 2022 and 1% in 2023. Performance payment adjustments (PPAs) reflect the Modality Performance Score and apply to claims for all dialysis patients. The PPAs begin in July 2022. How bonuses and penalties are set is unchanged, but the scale of maximum bonuses and penalties has been reduced. For the first two PPAs, the maximum penalty has been reduced from 8% to 5% for dialysis facilities and from 6% to 5% for nephrology practices.
CMS has issued a waiver for the decade-old kidney disease education (KDE) benefit. Ordinarily, KDE is reserved for patients with CKD stage 4 and must be delivered by physicians, nurse practitioners and physicians assistants. In ETC, KDE may be delivered to patients with CKD stage 4 or 5 and to patients in the first 6 months of dialysis, and both dietitians and social workers may also furnish KDE.
Questions about ETC remain
The final form of ETC raises a lot of interesting questions, some of which will take months or even years to answer. During the demonstration, dialysis providers and nephrology practices will often ask themselves about current performance, especially with respect to benchmarks. Clearly, there is remarkable variability in home dialysis utilization among the HRRs. Timely data that are limited to patients with Medicare fee-for-service coverage will be needed.
Will CMS provide ongoing updates about home dialysis utilization? Who will provide data about transplant wait-listing registration?
One type of dialysis provider will always know where it stands, at least with respect to home dialysis utilization: a provider that offers only home dialysis. Regardless of how frequently patients discontinue home dialysis and return to in-facility hemodialysis, patients in a “home-only” provider will collectively produce home dialysis utilization of 100%. Will home-only providers grow? If these grow, how will these be evaluated?
The ETC model includes only patients with traditional Medicare. There are more than 300,000 such patients today. However, open enrollment has begun and this one is unprecedented. Patients currently on dialysis may migrate from traditional Medicare to Medicare Advantage plans. Performance in ETC may evolve in unpredictable ways as MA enrollment grows.
How will providers grow home dialysis? There are two levers: home hemodialysis and peritoneal dialysis. In ETC, the performance measure reflects existing patients on dialysis. The big pool in ETC includes patients on in-facility hemodialysis who could dialyze at home – probably using home hemodialysis. Growing peritoneal dialysis in new patients is laudable, but not the direct path to success in ETC.
Growth opportunity
The future of in-facility self-care dialysis is a mystery. There are essentially two pockets of this care model that are apparent in Medicare claims – one around Waco, Texas, and another in Philadelphia. CMS is implicitly inviting the growth of this care model, but what constitutes self-care is not universally understood.
Transplant wait listing is a multi-step process, beginning with a referral. There are now multiple entities with competing measures. In ETC, dialysis facilities are incented to list patients. Kidney transplant centers mind wait-list mortality, which is likely to increase if relatively complex patients are listed. The give and take between dialysis providers and transplant centers will be complex.
The ESRD Treatment Choices model has the potential to transform the dialysis delivery system in the United States. Dialysis providers and nephrology practices in about one-third of the United States have much to consider in the coming months and years.
- For more information
- Eric Weinhandl, PhD, MS, is an epidemiologist with the Chronic Disease Research Group, based in Minneapolis. He is also a member of the Editorial Advisory Board for Nephrology News & Issues. He can be reached at eweinhandl@cdrg.org.
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