Healio Special Report: Health Care and Politics

Healio Special Report: Health Care and Politics

September 18, 2019
4 min read

Citing ‘methodological concerns,’ MedPAC advises CMS not to launch ESRD Treatment Choices payment model

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In a letter released earlier this month, the Medicare Payment Advisory Commission urged CMS Administrator Seema Verma to not implement its ESRD Treatment Choices model, a program that would provide financial incentives of up to 3% to nephrologists and dialysis providers who increase the number of patients treated with home dialysis or who achieve a higher rate of kidney transplantation.

A proposed rule for the model was released on July 10 as part of the executive order signed by President Donald J. Trump that created Advancing American Kidney Health.

“Crucially, our new system will ensure that more patients undergoing dialysis can do so from the comfort of their own home. And doing this from the home is a dramatic, long-overdue reform — something that people have been asking for for many, many years,” Trump said.

However, in a 15-page letter sent Sept. 3 to Verma, MedPAC chair Francis J. Crosson, MD, said the commissioners had “significant methodological concerns such that we believe CMS should not implement the proposed ESRD Treatment [Choices] ETC model.”

“We believe the proposed measurement of home dialysis and kidney transplantation rates in the [performance payment adjustment] PPA lack sufficient validity to serve as the basis for the payment incentives. For both the home dialysis and transplant measures, we have specific concerns about the reliability of the measurement; the comparison-to-control-group benchmarks and scoring method; the risk-adjustment method; and, in certain instances, the alignment of incentives for participants,” Crosson wrote.

Measuring the kidney transplant rate at the facility level, for example, “is not likely to produce reliable estimates and may not allow for an operational scoring method for the ETC,” the letter said. “CMS did not provide any information about the distribution of facility-level transplant rates, but we are skeptical that the measure is sensitive to a facility’s effort to increase transplant rates.”

The ETC model approach to increase home dialysis patients had similar flaws. “Home dialysis rates are not uniform geographically, and we are concerned that random assignment of [hospital region rates] HRRs would not generate equal distributions of home dialysis rates among the participants in each group,” Crosson wrote. “In this proposed rule, CMS has not explained whether it would check that the distributions of home dialysis rates in treatment and control HRRs are equivalent after randomization, nor has it described a remedy if it discovered nonequivalent home dialysis distributions in the treatment and control groups.”

The ETC model could also provide mid-sized and large dialysis providers “conflicting incentives that undermine the goal of increasing the national home dialysis rate,” Crosson wrote. “Mid-sized and large dialysis organizations will likely operate facilities that will be assigned to the treatment group in some HRRs and the control group in other HRRs. The design of the model (ie, the set of financial incentives) would potentially put these providers in the awkward position of maintaining a status quo level of effort in control HRRs while exerting additional effort to increase home dialysis rates in treatment HRRs. The diverging incentives of treatment and control HRRs could affect organizational decisions such as the opening or closing facilities, the location of home dialysis programs, and a myriad of other decisions about the allocation of organizational resources.”

Crosson added, “Furthermore, the model’s incentives may unintentionally result in these organizations waiting until the model terminates to implement best practices organization-wide.”

MedPAC commissioners were also concerned that the ETC does not measure beneficiary experience. “Given the ETC model’s potential effect on beneficiaries’ care, we urge CMS to implement a more formal approach to assess beneficiaries’ experiences, such as developing a home dialysis [Consumer Assessment of Healthcare Providers and Systems] CAHPS instrument. Assessing patient experience is a key component in the Commission’s principles for measuring quality. These concerns also apply to monitoring the experience of beneficiaries undergoing a transplant,” according to the letter.

Instead of using the ETC model methodology, the commissioners believe that CMS should instead implement an approach similar to the Comprehensive End-Stage Renal Disease Care (CEC) model that could “provide a holistic approach to the care of beneficiaries with CKD, who often have multiple comorbidities in addition to kidney disease” and “hold both dialysis facilities and managing clinicians jointly accountable for the outcomes (quality, utilization, and financial) of beneficiaries with CKD, including rates of home dialysis and transplantation. Kidney transplant centers should also be considered to participate in such a model.

“Overall, the commission believes that the ETC model, while laudable in its goal of increasing home dialysis use and kidney transplantation among ESRD beneficiaries, is too narrowly focused and does not promote holistic care for the multiple chronic and acute conditions that ESRD beneficiaries face,” Crosson wrote. “The commission believes that CMS should implement a broader approach under a shared savings program, which would hold both dialysis facilities and managing clinicians jointly accountable for all the care furnished to their patients with advanced CKD.

“We have previously said that a shared savings program for dialysis facilities and managing clinicians, if structured properly, could present an opportunity to transform the [fee-for-service] FFS delivery system, improve care management and coordination, and reward providers who are doing their part to control costs and improve quality.

“By contrast, the narrow scope of the proposed ETC model — focusing on increasing only home dialysis use and kidney transplantation — does not address some of the undesirable incentives inherent in FFS payment (such as the lack of collaboration among health care providers to coordinate a patient’s care),” according to the letter.