To reach home dialysis goals, reward surgeons, hospitals, programs that support efforts
Increasing the use of peritoneal dialysis can help the kidney care community reach Advancing American Kidney Health goals, but CMS will need to re-think incentives beyond what newly proposed payment models are offering nephrologists and dialysis providers, according to an editorial.
“The [Advancing American Kidney Health] AAKH has undoubtedly increased excitement among the nephrology community, specifically as it relates to home dialysis,” Eric L. Wallace, MD, and Michael Allon, MD, nephrologists at the University of Alabama at Birmingham, wrote. “As the initiative has the potential to dramatically change the face of nephrology care in the United States, it is critical that all steps be taken to ensure its success. Poorly executed efforts to rapidly increase home dialysis without promoting and funding a robust infrastructure may result in suboptimal outcomes, thus having an unintended, prolonged negative effect on home dialysis.”
The Advancing American Kidney Health has three major goals: by 2030, reduce the number of Americans developing ESKD by 25%; have 80% of new patients with ESKD in 2025 either receiving dialysis at home or have a functioning kidney transplant; and doubling the number of kidneys available for transplant by 2030.
Wallace and Allon believe current financial incentives to achieve these goals, now proposed by CMS in the ESRD Treatment Choices (ETC) model, need to be dispersed more widely to have a broader impact on increasing home dialysis. As proposed, the ETC model would randomize patients starting on dialysis into one of two treatment groups. Centers and nephrologists who are part of the ETC will receive a home dialysis payment adjustment during a 3-year period if they increase their home population for 3 years, and an incentive payment for kidney transplant up to $15,000 during the first 3 years of transplant.
However, additional incentives should be given to other individuals and partners involved in helping providers reach the Advancing American Kidney Health goals, particularly for peritoneal dialysis.
“A successful PD program requires a comprehensive infrastructure that, at a minimum, includes operators trained in PD catheter insertion and revision, a key omission from the ETC incentives,” the authors wrote. “Many centers struggle to find one operator to place these accesses, let alone a group capable of placing the volume of catheters needed for this initiative. Revisions of PD catheters is just as concerning a problem as placement, as this requires primarily urgent surgical interventions to ensure technique survival. Incentives for operators with performance bonus would be highly advisable to ensure the success of the ETC.”
Hospitals should also be rewarded that encourage and care for home dialysis patients. “[These hospitals] lack the ability to care for home dialysis patients, including trained staff, nephrologists, and stocked home dialysis supplies,” the authors wrote. “Incentives for these hospitals to care for home dialysis patients would also help ensure the ETC success.” Lastly, “there is no provision for nursing facilities to offset costs of nurse training required to care for patients on PD,” they wrote.
Funding in the ETC model should also be directed at paying for assisted PD for patients with mental or social challenges, and development of standard education for all patients with CKD stage 4.
Another ETC model funding opportunity is Project Extension for Community Healthcare Outcomes (ECHO). Project ECHO is a program “that disseminates expertise from centers of excellence to smaller sites,” the authors wrote. “Furthermore, support for home dialysis fellowships through post-graduate funding could go a long way to increase home dialysis expertise in this country.”
“These steps are critical to achieve the desired goal of increasing home dialysis, while at the same time ensuring that patient outcomes are not jeopardized,” they wrote. - by Mark E. Neumann
Disclosures: Wallace reports grants and personal fees from Baxter Healthcare Corp, personal fees from Davita Inc., grants and personal fees from Sanofi, personal fees and other from Idorsia, Protalix and Freeline Therapeutics outside the submitted work. Allon reports personal fees from CorMedix outside the submitted work.