CMS rules may limit patient choices for kidney care
Key takeaways:
- The End-Stage Renal Disease Treatment Choices model is a mandatory value-based care program from CMS.
- The model is intended to encourage home dialysis use and transplantation.
LAS VEGAS — The CMS End-Stage Renal Disease Treatment Choices model was designed to offer optimal care while cutting Medicare expenses, but policy may not always have the intended effect, according to a speaker.
Eugene Lin, MD, MS, FASN, assistant professor of medicine at the Keck School of Medicine of the University of Southern California, and Healio | Nephrology News & Issues Editorial Board Member, discussed pros and cons of the value-based care program at the Annual Dialysis Conference.
“[We wanted to cover] how the policy environment is moving in the United States toward the 21st century ... and the flurry of government and policy activity around kidney care,” Lin told Healio after the presentation. “Starting around 2011, kidney care and dialysis care was mostly centered on a bundled payment system, and that policy environment was fairly static.”
Today, he added, “a number of new dialysis funding programs have been added to the bundle that made that [policy] environment and that financial environment a lot more complex.”
The ESRD Treatment Choices (ETC) model is a mandatory measure developed by CMS intended to encourage home dialysis use and transplantation for patients with advanced kidney disease. The model has gained some support, Lin said, but CMS should emphasize preventive measures, such as early disease detection, chronic kidney disease management and preemptive transplantation.
The program combines payments for dialysis, medication and other services into one reimbursement structure adjusted for geography, patient traits and facility factors. The structure has expanded to include injectable medications, dialysis drugs and related services, but these and other additions have introduced complexity to the reimbursement model.
“So, No. 1, there have been new add-on payments for new technologies and new drugs,” Lin said. “No. 2, we have seen value-based care initiatives, both with respect to quality of care, but also incentivizing home dialysis and transplantation.”
Specifically, CMS-introduced add-ons including the Transitional Drug Add-on Payment Adjustment (TDAPA) and Transitional Add-on Payment for New and Innovative Equipment and Supplies (TPNIES), developed to support new therapies and technologies.
Payment bundle additions could reduce unnecessary medication use, such as erythropoiesis-stimulating agents, and promote home dialysis, Lin said. But fixed payments could also incentivize providers to cut costs at the expense of patient care. Plus, including new drugs and technologies could complicate things because not all dialysis-related injectable medications qualify.
Lin also mentioned the growing role of Medicare Advantage, how the bundle interacts with alternative structures and whether value-based care can be effective across different payers.
It is important providers and patients be familiar with the different funding mechanisms, Lin said.
“There are a number of other models that are either about to start or are being sunset ... and we need to think about how providers can adapt to a different funding environment, and how they can modernize so they can stay financially viable and afloat,” Lin said.
As CMS continues to refine the ESRD bundle, patients and providers should advocate for quality measurement, performance metrics and a shift toward disease prevention, Lin said. Innovations like AI, telehealth and electronic health records could help this transition.
By prioritizing early intervention and disease management, according to Lin, the ESRD bundle can enhance patient care while controlling costs.
Reference:
CMS.gov. ESRD Treatment Choices (ETC) model. https://www.cms.gov/priorities/innovation/innovation-models/esrd-treatment-choices-model. Accessed March 19, 2025.
For more information:
Eugene Lin, MD, MS, FASN, can be reached at eugene.lin@med.usc.edu.
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Lin E, et al. Deciphering the complexities of CMS’ standard payment model: A comprehensive overview. Presented at: Annual Dialysis Conference; March 13-16, 2025; Las Vegas.