Issue: December 2020
Disclosures: Riopelle reports no relevant financial disclosures.
December 10, 2020
2 min read

ESRD Treatment Choices presents a better model of care

Issue: December 2020
Disclosures: Riopelle reports no relevant financial disclosures.
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On Sept. 18, CMS released its final rule for the End-Stage Renal Disease Treatment Choices model, covering kidney care providers across nearly one-third of the United States.

The ESRD Treatment Choices (ETC) model was created as part of the 2019 Advancing American Kidney Health executive order and is the first mandatory kidney care model to come out of the innovation center at CMS.

In many respects, ETC is another example of an unprecedented and exciting time for kidney care. The nephrology specialty has seen more innovation in the last 18 to 24 months than in the past 30 years.

With one in three American adults at risk for developing kidney disease, a new focus on upstream patient management, education and prevention has moved kidney care into the spotlight. New CMS initiatives, technological advancements in remote monitoring and COVID-19 have also added urgency to home-based care.

Chris Riopelle

Aggressive timeline

ETC is launching under an aggressive timeline, which may create short-term challenges for kidney care providers. CMS will introduce adjustments to Medicare fee-for-service reimbursements to dialysis facilities, nephrologists and other nephrology clinicians (eg, nurse practitioners) based on their home dialysis and transplant rates. The goal is to become more cost-efficient while improving patient outcomes, decreasing the number of people receiving dialysis in center and increasing kidney transplants. CMS projects the initiative will save $23 million in the course of 5.5 years.

To maximize payment adjustments, dialysis facilities and nephrologists must outperform benchmarks set for home dialysis and kidney transplant rates. These benchmarks are determined by the performance of comparable geographies that are not part of the ETC model, mixed with providers’ own historical performance.

ETC is not without its methodological limitations, but the program provides a clear roadmap of the future of the industry. Nephrologists will need additional care pathways. Traditional dialysis facilities will need to invest more aggressively in adding home dialysis as an option if they have not already. Understand, there is not a simple fix, as kidney care is complex and value-based kidney care swims against the current of the industry’s legacy incentive model.

Commercial payers

The high and continuous cost associated with the disease has CMS keen to introduce kidney-centric models. While ESRD accounts for less than 1% of the Medicare population, it makes up more than 7% of Medicare expenditures. ETC is the latest example of the commitment of CMS to move kidney care into value-based models that emphasize pathways with lower costs and better outcomes, such as home dialysis and transplant.

Importantly, ETC is complementary to the Kidney Care Choices (KCC) voluntary models, and participants can be involved with both programs. With ETC and KCC models emphasizing home dialysis and transplant, expect more nephrology practices to either invest in new technology, care team resources and workflows to support expanded care options or partner with specialized value-based kidney care companies that have already made these investments.

Overall, ETC indicates an aggressive movement toward value-based kidney care. Expect ETC to be one of several large-scale initiatives that will drive fundamental change in how kidney care is delivered and reimbursed.

Now that CMS has taken a position toward value-based kidney care, we expect commercial payers to follow suit. Nephrologists who participate in multiple value-based care arrangements with various payers can apply the same infrastructure and investments toward all these efforts, which may reduce the impact of possible upfront costs.

The industry needs to work together to find ways to engage patients in identifying kidney disease earlier, promoting home modalities and closing care gaps. Initiatives like ETC add a spotlight on the topic that will help drive change and expand treatment options, including transplants and home-based care.