CMS needs to push ESRD Treatment Choices, Kidney Care Choices models to direct change
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Kidney care has long been a particular pain point in the health care system, but reform is on the way.
CMS’s planned January 2021 launch of the End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model, which imposes a mandatory model linking provider reimbursement to transplant and home dialysis rates, is an important step in the right direction, but there is more we can do.
The goals of the ETC are right: home dialysis costs less and leads to better outcomes than in-center treatment, but too few Americans dialyze at home today. In fact, the U.S. home dialysis rate is around 10%, while most developed countries have three to four times that rate.
By incentivizing dialysis providers to increase in-home care rather than simply connect patients to in-center machines, the ETC hopes to dramatically improve these numbers and give more Americans with kidney failure the benefits of being treated at home.
Likewise, people with ESRD are also better served by greater access to transplants, which are the best treatment for kidney failure. Unfortunately, the average American wait time for a kidney is 5 years — worse than most developed countries and even some less-developed ones. What is more, today there are 100,000 Americans languishing on the transplant waitlist.
More flexibility
The challenge, however, is the ETC does not go far enough. To truly drive change in kidney care, the incentives need to move upstream from renal replacement therapies to earlier diagnosis and intervention before kidney failure. Once a patient needs dialysis, it is often too late to arrange in-home care, especially when so many patients begin dialysis via the ER. Instead, physicians and other health care providers must be reimbursed for engaging patients earlier in the course of their disease, educating them about therapy options and preparing them for the next phases of their kidney care journey, whether it is dialysis, a transplant or another alternative.
To do that, we need to get physicians and other providers the support they need. This includes more options for patients, more ways to intervene with patients and more resources. Creating value-based care arrangements is at the heart of this shift: rather than providing fee-for-service, provider compensation should link to long-term outcomes, while payers would provide an array of resources for reaching these goals.
Patient education, support
To reduce the exorbitant long-term costs of care, we need to invest in patient education and support when people first receive their chronic kidney care diagnosis. Rather than having a quarterly nephrologist visit to check blood levels, patients should receive comprehensive, high-touch care that supports and educates them as they manage their disease through diet and behavior change.
A nephrologist may instruct a patient to reduce salt intake, but even with the best of intentions, this instruction often goes unheeded, leading to severe long-term consequences. Providing patients with easy access between doctor appointments to a dietitian, peer support and other multidisciplinary means of care gives patients the needed assistance to facilitate difficult behavior change.
The good news is that more change is coming. CMS is launching a voluntary program next year – the Kidney Care Choices model – to encourage providers to engage more with kidney patients prior to kidney failure. In addition, more commercial insurers are exploring value-based arrangements for kidney patients every year. These changes will not happen overnight.
The ETC Model is not perfect, but it is a worthy first step. Still, we must continue to support changes that improve care for patients who have not yet progressed to kidney failure, whether commercially insured or covered by government programs. Only by pursuing value-based models will we be able to finally change the incentives necessary to create healthier, lower-cost kidney care for all.
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- Robert Sepucha is the CEO for Cricket Health, based in Boston.
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