Issue: December 2020
Disclosures: Giullian and Becker report no relevant financial disclosures.
December 10, 2020
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ESRD Treatment Choices model can transform kidney care

Issue: December 2020
Disclosures: Giullian and Becker report no relevant financial disclosures.
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We are energized by the impact kidney care policy reform can have on the speed of change within nephrology.

The final rule for the End-Stage Renal Disease Treatment Choices (ETC) model catalyzes a vision that supports the complex medical needs of patients with kidney disease by increasing opportunities for shared decision-making for home dialysis options and improving rates of kidney transplantation. The ETC model begins on Jan. 1, 2021.

Jeffrey Giullian

Fundamental goals

For the 30% of dialysis centers and clinicians who are selected and required to participate in the ETC model, the fundamental goals are to increase home dialysis and transplants by:

Bryan Becker
  • providing incentives to support patients dialyzing at home through an increase in the home dialysis payments for 3 years and payment adjustments for dialysis-related services. The payments are adjusted either upward or downward, based on home dialysis adoption rates; and
  • making payment adjustments, either upward or downward, based on the rates of patients on the transplant waitlist and those who receive living donor transplantation.1

Value-based models, like ETC, can empower patients to choose care at home, giving them freedom and flexibility in their treatment schedule. This allows patients to spend more time with their loved ones and more time working and participating in activities they enjoy.

Through ongoing federal policy advocacy, it is possible to empower more patients, physicians and care team members with greater remote communication opportunities via telehealth, helping patients sustain freedom and be more confident in their ability to engage in care and connect with the care team.

Improving coordination of care is another important step. Through value-based care programs, patients can receive coordinated care for their kidney and non-kidney care needs, including more collaborative comorbid condition management. This coordination can improve the overall patient experience and clinical outcomes.

More kidney transplants

Improving access to transplantation is the third piece is this process. Although a kidney transplant is often the best option for eligible patients with ESRD, social determinants of health, including race, have a significant impact on which eligible patients referred to a transplant center ultimately get placed on a waitlist or receive a kidney transplant.2 Value-based models can incentivize greater communication and coordination among nephrologists, dialysis providers and transplant centers, thus improving access for all eligible patients.

As empowering patients to choose home treatment and improving the rate of transplantation are directly related to the goals of the ETC model, we take a deeper dive into those two initiatives.

Education is key to empower patients to choose a home modality. We have found patients who attend a class or receive bedside education on treatment options for kidney disease are more likely to choose home dialysis.3,4

We view technology as an essential adjunct to education to empower human connection differently and instill confidence among our patients while also offering flexibility. By delivering additional innovation like home remote monitoring and a multifaceted telehealth platform, the kidney community can progress in our joint goal to use technology to deepen and broaden the personal connection between patients and care teams, even when they are not regularly in center.

Dialyzing at home is associated with improved quality of life for patients.5 Yet, some patients who choose home dialysis will not be able to continue at home due to complications (eg, peritonitis) or issues involving their environment or care partners. It is important to have a safety net of high-quality, in- center hemodialysis treatment to catch these patients. This way, they can continue treatment longer with a focus on quality of care, access to transplantation while still pursuing their desired quality of life.

Improving the rate of transplantation is also key. In 2019, we asked physicians who work with us to help every patient who wants a kidney transplant by referring them to a transplant center for evaluation. This endowed the nephrologist with the critical responsibility of supporting each patient in the pursuit of his or her transplant goal and acknowledged the all-important role of the transplant center in determining if a patient is medically and psychosocially fit for placement on the waitlist.5

With so few available kidneys, the wait for a deceased donor transplant can be long. Through educational and waitlist support programs, patients who choose a kidney transplant are better able to get and stay transplant ready. Education is essential to empowering patients if they pursue a living donor or deceased donor kidney transplant. It helps support patients through their transplant journey. These transplant-enablement efforts have contributed to improved transplant rates in recent years.

Transform kidney care

Success in the ETC model can be supported by a shift in how physicians and dialysis centers partner to care for patients. This is exciting, albeit immensely challenging.

This shift allows for a more holistic approach to care including education, comorbidity management, attention to social determinants of health and assistance with navigating the complexities of health care systems. If physicians and centers can come together to address these clinical and non-clinical needs, all stakeholders have the opportunity to benefit from the model. Equally as important, if we do this, we will be better prepared to integrate other features of value-based care we will meet in the near future.

Beyond the ETC model

While not perfect, the ETC model is a key step in transforming kidney care. However, to fully realize its vision of the ETC model, we believe additional steps, such as removing regulatory restrictions and expanding education for patients at all stages of chronic kidney disease, are necessary. This expansion should include education facilitated by kidney care organizations and providers. With these types of innovations, the ETC model along with other integrated care models may not only help improve the lives of patients, but also satisfaction for physicians as they lead multidisciplinary teams that can focus more holistically on patient care.

With a powerful, collective force behind these efforts, we believe that together, we can fully realize integrated care as a reality for the most patients with kidney disease in the United States.