Congressional members cite lack of patient choice, unrealistic goals in ESRD Treatment Choices model

Suzan DelBene

A letter signed by 74 members of Congress and led by Kidney Caucus chair Larry Bucshon, MD, R-Ind., and co-chair Rep. Suzan DelBene, D-Wash., urges CMS to fix “serious design issues” in the mandatory ESRD Treatment Choices model before issuing a final rule.

“We agree that increasing the number of patients choosing home dialysis and receiving a kidney transplant are laudable goals but fear these goals will not be met unless meaningful changes to the model are made,” according to the Oct. 17 letter they wrote to HHS Secretary Alex M. Azar II and CMS Administrator Seema Verma.

Bucshon and DelBene, who has pushed for additional funding for the Kidney Accelerator Project, or KidneyX, wrote with their colleagues, including five physicians in Congress, that the ESRD Treatment Choices (ETC) model pushes aggressive goals for increased use of home dialysis and transplantation that bypass patient choice and place unrealistic expectations on how much control dialysis providers have on increasing transplants.

“The model seeks to incentivize nephrologists and facilities to place patients on home dialysis but has a flawed metric to determine a patient's propensity for home dialysis and does not account for patient choice,” according to the letter. “The model as proposed uses the CMS hierarchical condition category (CMS-HCC) risk scores to determine a patient's propensity to use home dialysis. We recommend that CMS replace this risk score with a metric that accounts for a patient's clinical status, including activities of daily living, as well as their ability and willingness to use home dialysis. This metric should be designed in such a way to properly align payment incentives with the best modality for the patient.”

Larry Bucshon

The Congressional leaders were also critical of the size of the ETC model demonstration – at least 50% of the ESKD population designated by hospital referral areas would be part of the project. Some organizations in the kidney community have suggested a smaller patient census for the demonstration.

“We ask the Innovation Center to minimize the number of providers to as few needed as possible to [track] transplant rates separately or develop an alternative to ensure an adequate sample in a smaller segment of the country,” they wrote.

The Congressional members also suggested to Verma and Azar that the ETC model include a method to measure patient satisfaction.

“Patient satisfaction is crucial to determine provider performance and we are concerned by the ETC model's lack of a formal measure of the beneficiary experience,” the members wrote.

Finally, the letter questioned the ETC model’s plan to hold dialysis clinics accountable for poor performance in improving transplant rates.

“Under current law, many of the barriers to transplant cannot be overcome solely by dialysis facilities or nephrologists,” the Congress members wrote. “We ask that the Innovation Center develop metrics that would hold facilities accountable for their rates of referral for a transplant workup and patient waitlist status ... Such metrics should recognize clinical eligibility for transplant and patient choice, including religious exemptions for patients. Holding providers accountable for their roles in the transplant process should be paired with holding the organ procurement organizations accountable with the new performance metric being proposed in the Hospital Outpatient Prospective Payment System for Calendar Year 2020. If the supply of transplantable organs doesn't increase, providers will be unable to improve their transplant rates.” – by Mark E. Neumann

References: https://kidneycarepartners.com/wp-content/uploads/2019/10/ETC-Kidney-Model-FINAL-SIGNED.pdf

www.healio.com/nephrology/policy-and-politics/news/online/%7B541b0fb1-5284-47a6-b8ef-5a1c77a0f802%7D/members-of-us-house-of-representatives-show-support-for-kidneyx

Suzan DelBene

A letter signed by 74 members of Congress and led by Kidney Caucus chair Larry Bucshon, MD, R-Ind., and co-chair Rep. Suzan DelBene, D-Wash., urges CMS to fix “serious design issues” in the mandatory ESRD Treatment Choices model before issuing a final rule.

“We agree that increasing the number of patients choosing home dialysis and receiving a kidney transplant are laudable goals but fear these goals will not be met unless meaningful changes to the model are made,” according to the Oct. 17 letter they wrote to HHS Secretary Alex M. Azar II and CMS Administrator Seema Verma.

Bucshon and DelBene, who has pushed for additional funding for the Kidney Accelerator Project, or KidneyX, wrote with their colleagues, including five physicians in Congress, that the ESRD Treatment Choices (ETC) model pushes aggressive goals for increased use of home dialysis and transplantation that bypass patient choice and place unrealistic expectations on how much control dialysis providers have on increasing transplants.

“The model seeks to incentivize nephrologists and facilities to place patients on home dialysis but has a flawed metric to determine a patient's propensity for home dialysis and does not account for patient choice,” according to the letter. “The model as proposed uses the CMS hierarchical condition category (CMS-HCC) risk scores to determine a patient's propensity to use home dialysis. We recommend that CMS replace this risk score with a metric that accounts for a patient's clinical status, including activities of daily living, as well as their ability and willingness to use home dialysis. This metric should be designed in such a way to properly align payment incentives with the best modality for the patient.”

Larry Bucshon

The Congressional leaders were also critical of the size of the ETC model demonstration – at least 50% of the ESKD population designated by hospital referral areas would be part of the project. Some organizations in the kidney community have suggested a smaller patient census for the demonstration.

“We ask the Innovation Center to minimize the number of providers to as few needed as possible to [track] transplant rates separately or develop an alternative to ensure an adequate sample in a smaller segment of the country,” they wrote.

The Congressional members also suggested to Verma and Azar that the ETC model include a method to measure patient satisfaction.

“Patient satisfaction is crucial to determine provider performance and we are concerned by the ETC model's lack of a formal measure of the beneficiary experience,” the members wrote.

Finally, the letter questioned the ETC model’s plan to hold dialysis clinics accountable for poor performance in improving transplant rates.

“Under current law, many of the barriers to transplant cannot be overcome solely by dialysis facilities or nephrologists,” the Congress members wrote. “We ask that the Innovation Center develop metrics that would hold facilities accountable for their rates of referral for a transplant workup and patient waitlist status ... Such metrics should recognize clinical eligibility for transplant and patient choice, including religious exemptions for patients. Holding providers accountable for their roles in the transplant process should be paired with holding the organ procurement organizations accountable with the new performance metric being proposed in the Hospital Outpatient Prospective Payment System for Calendar Year 2020. If the supply of transplantable organs doesn't increase, providers will be unable to improve their transplant rates.” – by Mark E. Neumann

References: https://kidneycarepartners.com/wp-content/uploads/2019/10/ETC-Kidney-Model-FINAL-SIGNED.pdf

www.healio.com/nephrology/policy-and-politics/news/online/%7B541b0fb1-5284-47a6-b8ef-5a1c77a0f802%7D/members-of-us-house-of-representatives-show-support-for-kidneyx

    See more from Healio Special Report: Health Care and Politics