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ETC model shows renewed focus on kidney care

Insight Article - December 15, 2020

Medicare Payment Policies

Population Health

Shika Pappoe MD, MPH
Kidney care is changing. On Jan. 1, the Centers for Medicare & Medicaid Services (CMS) kicked off a new care model for Medicare beneficiaries with end-stage renal disease (ESRD), which is projected to save $23 million over five and a half years.1 While cost should be a consideration in healthcare, the real promise comes with the potential improvements in patient outcomes. 

The ESRD Treatment Choices (ETC) Model was introduced under the 2019 Advancing American Kidney Health Executive Order and encourages more home dialysis and kidney transplants. Announced with the Kidney Care Choices (KCC) Model, the ETC Model marks the first time the CMS Innovation Center has issued a mandatory kidney care model.

This focus on kidney care is needed — one-third of U.S. adults are at risk for developing chronic kidney disease (CKD), and most afflicted with it are not diagnosed until later stages. In fact, the National Kidney Foundation notes that about half of the people with very low kidney function and not on dialysis are unaware that they have CKD.2

Kidney disease often is intertwined with the broader increase in chronic diseases in the United States: About 1 in 3 adults with diabetes and 1 in 5 adults with high blood pressure may also have CKD.3 Education and prevention efforts related to kidney disease are necessary aspects of treatment for these conditions to reduce the number of CKD cases and prevent its progression.

Innovation is now happening in nephrology on several fronts, focusing on education, prevention and care coordination. COVID-19 has increased the focus on home-based care, and reimbursement — which traditionally has been lacking and held back adoption of new approaches to care — is catching up. Despite areas for improvement, the ETC Model is a shift in the right direction.

The ETC Model covers a significant portion of kidney care providers — nearly one-third across the country. Announced in September 2020, it is launching with an aggressive timeline that leaves only a few months to make any necessary changes to care options for nephrology practices.

Shifting fee-for-service to value-based payment, the ETC Model’s goals are improving cost-efficiency and patient outcomes by decreasing the amount of people receiving dialysis in centers and increasing kidney transplants. Jan. 1 will see CMS introduce reimbursement adjustments to dialysis facilities, nephrologists and other nephrology clinicians based on their home dialysis and transplant rates.

Per-treatment and per-patient, per-month (PMPM) reimbursements are impacted by ETC, beginning with positive adjustment for all home dialysis claims in 2021 and risk increases each subsequent year. By 2026, nephrologists’ relevant claims will be adjusted from 9% lower to 8% higher. This represents an aggressive shift toward value-based kidney care and is the first of several initiatives that will alter kidney care delivery and reimbursement.

To receive maximum reimbursement, participating nephrologists must outperform benchmarks set for home dialysis and kidney transplant rates. These benchmarks combine the providers’ historical performance with that of comparable geographies that are not part of the ETC Model. CMS selects participants based on randomly selected geographic areas. Even for providers already exploring value-based care, this requires a shift in delivering patient care.

As home dialysis and kidney transplant rates are main focuses of the ETC Model, and participation is not voluntary, many kidney care providers may face short-term challenges setting up additional care pathways. Recognizing challenges, exclusions do exist in this new model, including for those:
  • under age 18
  • with an acute kidney injury
  • in hospice, nursing homes or skilled nursing facilities.

That said, the program provides clear goals to move the industry forward, with commercial payers likely to follow CMS’ lead with similar programs aimed at lower costs and better outcomes, such as home dialysis and transplant.

To maximize any investments made in moving to value-based care, nephrologists can also participate in KCC voluntary models, which are complementary to the ETC. Because of these programs, more nephrology practices will invest in new technology, care team resources and workflows to support expanded care options. Groups may also choose to partner with specialized value-based kidney care companies that have already made these investments.

Giving patients more flexibility on kidney care helps them adjust to treatment in ways that are less disruptive to their ability to sustain their livelihood and quality of life. It helps empower them to become more active participants in their care. During the current pandemic, it also could minimize exposure to coronavirus for a patient population at higher risk for complications.
  
Treating kidney disease is not simple and numerous factors complicate early diagnosis and delaying disease progression. Having early conversations with patients about treatment options improves outcomes. Value-based care programs, such as the ETC Model, encourage clinicians to care for the whole person and their quality of life beyond the diagnosis. The next few years will see a shift in treating kidney disease on multiple fronts, ultimately benefiting providers and patients.

Notes:

  1. CMS. “CMS Announces Transformative New Model of Care for Medicare Beneficiaries with Chronic Kidney Disease.” Sept. 18, 2020. Available from: go.cms.gov/34PO5O3.
  2. National Kidney Foundation. “Kidney Disease: The Basics.” Available from: bit.ly/35VTEtF.
  3. Ibid.

About the Author

Shika Pappoe
Shika Pappoe MD, MPH
Chief Medical Officer Strive Health Denver, CO

Shika Pappoe can be reached at spappoe@strivehealth.com.

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