After 2 years, the ESRD Treatment Choices model is – surprise – a bust
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Key takeaways:
- The failure of the End-Stage Renal Disease Treatment Choices model suggests financial incentives cannot replace “patient centeredness.”
- Studies do not show quality of life is always better on home dialysis.
In 2019, former President Donald Trump signed the Advancing American Kidney Health initiative.
Among the goals of the executive order were to reduce the number of patients developing kidney failure and to increase home dialysis and transplant rates.
Most members of the kidney disease patient and provider community welcomed the initiative because it would provide a long-overdue governmental prioritization of a disease that affects 37 million Americans and consumes one in five dollars spent by the traditional Medicare program.
One of the three goals of the Advancing American Kidney Health (AAKH) initiative was to “make it easier for patients to receive care at home or in other flexible ways,” with the aim of 80% of new patients receiving dialysis in the home or receiving a transplant by 2025.
As a means of incentivizing the shift to home dialysis and transplant, the CMS Innovation Center initiated the ESRD Treatment Choices (ETC) model, which is mandatory for a randomly selected 30% (by geographic area) of dialysis facilities and managing clinicians. Facilities randomized to the ETC model receive positive and negative adjustments to their bundled dialysis payment, and managing clinicians receive positive and negative adjustments to their monthly capitated payments based on their home dialysis and transplant rates — the rationale being that if payment is at-risk, facilities and clinicians would work harder to encourage their patients to shift from in-center to home dialysis or to undergo kidney transplant.
‘Person-centeredness’
As reported by Koukounas and colleagues, the strategy has not worked during the first 2 years of the ETC model (the demonstration continues through 2027). The proportion of patients receiving home dialysis increased from 12.1% to 14.3% in ETC regions and from 12.9% to 15.1% in non-ETC (control) regions.
There was no difference in the change in transplant rates.
The failure of the ETC payment model could have been predicted because it was not truly driven by the interest in “person-centeredness” that the AAKH espouses, but rather by cost savings, using financial incentives which did not work in the past. As in-center hemodialysis (ICHD) and peritoneal dialysis (PD) are paid at the same weekly rate and PD is less expensive to the dialysis provider than ICHD, there has always been a financial incentive to the dialysis provider to increase PD.
AAKH cherry-picked data regarding survival and quality of life (QoL) on home dialysis vs. ICHD to make a case for the former and to determine that home dialysis is a better option. Even so, in a patient-centered model the choice is ultimately up to the patient after considering the advantages and disadvantages of each modality.
Many cancer patients choose shorter survival but improved QoL without chemotherapy. A significant number of patients consider the ease of ICHD to be an overwhelming advantage compared with the flexibility of home modalities. What person-centeredness is all about is the process, not the outcome. It is about informed decision-making: Give the patient all the information about the advantages and disadvantages of each choice, then allow the patient (and other stakeholders such as family members who may be needed to implement the choice) to make the decision of what is best for them.
The improved QoL argument for home dialysis often falls flat. The ETC is flawed because it is about what the patient chooses, not about how the patient chooses.
Modality choice, survival and QoL
But what are the advantages of home dialysis?
Not survival with use of PD. A systematic review and meta-analysis propensity score-matching mortality comparison of PD and ICHD found equivalent survival benefits. Quality of life advantages of PD vs. ICHD are variable and patient-specific. A systematic review of patient-reported outcomes of QoL by dialysis modality showed five of nine studies with significant differences favoring PD, but three of these studies showed significant differences favoring hemodialysis in domains including general health, support from staff, sleep quality social support, health status, social interaction, body image and overall health.
Home hemodialysis (HHD), although it offers better survival than either PD or ICHD, is more expensive than ICHD if implemented at the recommended frequency of five to six treatments per week. Most Medicare administrative contractors pay for a maximum of four HHD treatments per week, and the cost of the additional one to two home HD treatments per week is absorbed by the dialysis provider. Therefore, in Medicare’s view, HHD is not more expensive than ICHD.
HHD is used by less than 2% of patients on dialysis in the United States, but its use may expand due to innovative user-friendly machines, softening provider requirements that patients who do not wish to self-cannulate can use tunneled catheters and the development of improved safety systems including blood leak detectors so patients do not require a partner to be present throughout the procedure.
The greatest barriers to increased uptake of home dialysis, in order of decreasing dialysis facility actionability, are inadequate patient education, lack of infrastructure, championing by managing clinicians and lack of informed patient acceptance.
In one frequently quoted study, Maaroufi and colleagues showed that 25% to 40% of patients reported they would select home dialysis if given the opportunity; however, only 24% of patients informed before and 8% of patients informed after starting dialysis were ultimately treated with PD. Reasons for the mismatch between dialysis modality preference and treatment delivered were equally distributed between medical and nonmedical, but the study demonstrates that treating patients with PD is less actionable (by those affected by the ETC) once the patient is on dialysis.
Reassess AAKH goals
AAKH was not conceived to improve the care of patients on dialysis; the aim is to decrease the cost of the Medicare ESRD Program by shifting to less expensive therapies and decrease the bundled payment for all modalities, which is the average cost of all modalities. There is no assurance in AAKH that any savings accrued by increasing PD and transplant will stay in the ESRD program or be used to augment upstream care of patients with chronic kidney disease by improving detection and treatment.
It has been 5 years since the AAKH was signed by former President Trump. Perhaps it is time to reassess its successes and failures in the context of a health care system that underserves the populations disproportionately affected by kidney disease and renal replacement therapy. The failure of the ETC to move the needle on home dialysis and transplant shows that payment incentives, positive or negative, are not effective if actionability by the provider is dwarfed by other barriers.
Reference:
Maaroufi A, et al. Am J Nephro. 2013;doi:10.1159/000348822.
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For more information:
Jay B. Wish, MD, is professor of clinical medicine at Indiana University School of Medicine and chief medical officer for dialysis at Indiana University Health in Indianapolis. He is also chair of the Healio | Nephrology News & Issues Editorial Advisory Board.
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