Dialysis centers and patient advocacy groups urged the CMS to reconsider its plan to increase home dialysis and kidney transplants and shift those providers to risk-based payments, saying the changes prevent patients from choosing the care they want.
In comments on a new pay model affecting kidney care, providers and patient advocates claimed the changes will create financial disincentives to recommend and deliver the best treatment option for affected Medicare enrollees. It rewards the use of home dialysis and kidney transplants while discouraging the use of in-center dialysis and excluding alternative treatment options.
The proposed End-Stage Renal Disease Treatment Choices Model would affect 50% of adult end-stage renal disease patients. The plan would realign financial incentives by increasing payments for certain home dialysis claims for three years and decrease other dialysis-related Medicare payments for both home and in-center dialysis treatments.
The Center for Medicare and Medicaid Innovation is proposing that the mandatory payments begin in January 2020 and end June 2026, but it's also considering an April 2020 start date.
The Innovation Center predicts the proposed model would cut Medicare spending while maintaining or improving quality because it increases providers' financial accountability.
Home dialysis and kidney transplants are the preferred treatment options for many end-stage renal disease patients, but some providers and patient groups think the Innovation Center exaggerated the clinical evidence, and choosing whether to receive treatment at home or in a dialysis center should be based on patient choice, not financial rewards.
"It is important that CMS not overstate the assumption of higher quality/better outcomes in-home dialysis compared with in-center dialysis," said Dr. Jeffrey Schelling, Director of the nephrology division at the MetroHealth System in Cleveland. "Providers should not be pressured to indicate the prospect of improved outcomes with home dialysis."
While there are many gaps in the delivery system that limit the uptake of home dialysis, some evidence shows there's less patient interest in home dialysis than the Innovation Center anticipates.
"We feel that an expectation that 80% of U.S. patients would choose home dialysis is unrealistic," wrote Hrant Jamgochian, CEO of Dialysis Patient Citizens.
Providers and patient advocates also worry that many people living with end-stage renal disease aren't good candidates for home-based dialysis because they lack the necessary supports at home to administer it effectively. They're concerned that the financial incentives created by the ETC Model will drive patients away from in-center dialysis, even though it might be their best treatment option.
"BSWH strongly supports excluding Medicare beneficiaries without stable housing," said Kristi Sherrill Hoyl, chief policy, government and community affairs officer for Baylor Scott & White Health. "It would be impractical for providers to be held accountable for outcomes in which it is necessary for the patient to have housing, but are unable to be housed."
There's also concern about kidney transplants. Most experts agree that kidney transplants are the best treatment option for end-stage renal disease patients in terms of quality of life, life expectancy and cost savings. But there aren't enough donors available.
Some providers and patient advocates argue that many patients aren't candidates for either dialysis or transplants, due to age or other conditions. They think the ETC Model should include palliative care for the seriously ill.
"The choices that are being offered — home dialysis and transplantation — are not the full menu of choices that CKD and ESRD patients need and want," said the Coalition for Supportive Care of Kidney Patients in its comments.
Providers and patient advocates also voiced concern that providers will take on too much financial risk for end-stage renal disease patients, especially early in the program when they may not have full capacity to administer home dialysis.
Delaying downside risk payments would allow providers to implement changes related to home dialysis and transplant rates before getting dinged for their performance, according to Duke Health's Private Diagnostic Clinic in its comments.
This isn't the first kidney-related pay model the CMS has released, and there could be overlap with the Kidney Care First Model and Comprehensive Kidney Care Contracting Models. Although the CMS said it would work to resolve overlap-related issues during the final rulemaking process, providers are skeptical.
"The dearth of specific information contained in this Proposed Rule puts potential participants at a significant disadvantage," stated Baylor Scott & White Health. "Without details of how the agency proposes to resolve overlaps, providers are unable to accurately forecast how the models may impact future revenues."
