End-Stage Renal Disease Treatment Choice Model 2021
James J. Matera DO, FACOI
Chief Medical Officer, CentraState Medical Center, Freehold, New Jersey
Matera JJ. End-stage renal disease treatment choice model 2021. Consultant360. Published online January 31, 2021.
Standard rates of end-stage renal disease (ESRD) in the United States rank among the highest in the world. Prevalent ESRD continues to rise, with almost 750,000 prevalent cases of ESRD reported in 2017.1 When it comes to the burden of cost on resources, total Medicare spending on patients with chronic kidney disease (CKD) and ESRD was in excess of $120 billion in 2017.1 It breaks down as follows:
- $84 billion for management of patients with CKD
- $36 billion for management of patients with ESRD
- This accounts for 7.2% of all Medicare paid claims, a number that has remained fairly constant for 10 years1
The Proposed ESRD Treatment Choice Model (ETC)
First put forward by former President Donald Trump in July 2019, the goal of this program2 was to treat 80% of patients on dialysis with a home therapy (home hemodialysis, HHD), peritoneal dialysis (PD), or renal transplantation by 2025. Current estimates are that this number is around 30%, while the number of home therapies for ESRD management (combined HHD and PD) is only about 12%, leading to the need for a significant increase to reach these goals.2
One of the reasons for such a low HHD population in the United States centers around education for patients with pre-ESRD.3 Use of pre-ESRD kidney dialysis education services is associated with significantly greater HHD use in Medicare beneficiaries with incident ESRD. In order to promote acceptance of patient education programs, we need to engage physicians, patients, and caregivers. This will be one key step in improving the home modality choices.3
Another factor that often arises when selecting modalities is the perspective of mortality. We all know that cardiovascular disease is the primary factor leading to morbidity and mortality in patients with ESRD. Although short-term mortality is lower for patients treated with PD than for those treated with hemodialysis, historically the long-term mortality risk is higher with PD.4 In the past 2 decades, the reduction in mortality risk has been greater for patients treated with PD than with hemodialysis such that, in most regions, the long-term survival of patients treated with PD and hemodialysis are now similar.4
Shared decision-making is also of prime importance when selecting a dialysis or transplantation modality for ESRD. This is where the nephrologist, or the nephrology team, in conjunction with dialysis education programs can help drive the home setting and increase transplantation awareness.5
Despite this, barriers often exist to choosing home modalities. Barriers specific to patients and/or caregivers include a lack of awareness, physical or cognitive barriers, social barriers such as care burden or out-of-pocket costs, physical space in the home, and fear of “bringing it home.” Potential solutions to reducing these barriers include education and training, care programs, home aides, home visits, policies to minimize costs, changes in reimbursement, education and counseling, and support groups.5
In addition, barriers specific to health care include accessibility issues, such as location and distance from home to training, infrastructure, delivery of supplies, economics, and bias.5 Potential solutions to these issues include increasing public advocacy and awareness through home training programs, support centers, incentive payments, a team approach to care, and education.5
There are many reasons for a lack of penetration into home modalities, besides barriers, that also depend on timing of nephrology referral, which can be random at best. This is an important area where nephrologists and primary care physicians need to work in concert. To be successful with the 2019 Executive Order, primary care physicians need to work with nephrologists so that patients can be educated about CKD and dialysis modalities earlier. Developing collegial and collaborative relationships with your nephrologist can improve this process.6
Traditionally, certain groups of patients have had lower rates of home dialysis, indicative of some direct or indirect bias in these groups. These include the elderly and disabled population and racial/ethnic minorities. Other bias occurs with patients who have not had pre-ESRD referrals during hospitalization. These patients, who may require emergent dialysis, are often defaulted to hemodialysis and have a central venous catheter (CVC) placed.7 It is estimated that more than 80% of patients starting hemodialysis have a CVC in place, indicating a lack of appropriate shared decision-making.8 Implementing programs like urgent-start PD7 can help lessen that burden and may facilitate:
- Education of late-referred patients without benefit of adequate education
- PD catheter placement in a timely manner, surgically or in interventional radiology suites
- Transition to intermittent PD in the hospital or transitional care unit where the patient can undergo urgent, low-volume PD and training to get to home
- These types of programs are increasing in number and are a good start to increasing numbers of home PD patients.
Prior studies have assessed the likelihood and timing of nephrology referral in patients with CKD. In 2018, the US Renal Data System showed that 35.4% of patients with incident ESKD had received little or no predialysis nephrology care.9 Moreover, in a study9 that included 2170 Black and White patients presenting at a primary care clinic in St. Louis, Missouri, the majority of patients with CKD were not referred to nephrology; however, those with faster rates of decline in estimated glomerular filtration rate (eGFR) and Black patients were more likely to be referred.9
Similarly, Winkelmayer and colleagues10 evaluated 3014 Medicare/Medicaid patients in New Jersey and defined “early referral” to nephrology as 90 days or fewer before the initiation of renal replacement therapy. This is very important because reducing cardiovascular disease risk in patients with CKD is essential, since it is the primary cause of morbidity and mortality in this population. Predialysis care utilizing a nephrologist improves nephrology-related outcomes as well as cardiovascular outcomes.11 Of course we need to follow this with the simple question, “why?” That will be a topic of future consideration for us.11
Renal transplantation is widely viewed as the best treatment for most patients with ESRD, generally increasing survival and quality of life while reducing medical expenditures. A minority of patients in 2017 (about 30%) had a functioning transplant, and even a small percentage had a transplant before starting dialysis (2.9%).8 These statistics lag behind many other developed countries and present an opportunity for improvement when engaging patients in potential therapies.8
What It Means For You
Practices participating in the ETC model would support patients with ESRD in choosing greater use of home therapies and transplantation. The managing clinician would be a Medicare-enrolled practitioner who provides and bills for the monthly capitation payment for managing one or more patients with ESRD.12
Under the model, there would be an enhancement of payments for participants starting in 2021 to encourage greater use of home modalities and transplantation:
Home Dialysis Payment Adjustment (HDPA)
- This is an increase in payments made for home dialysis and home dialysis-related claims during the first 3 years of the model. During this time, a performance payment adjustment will increase, and that will lead to a decrease over time to the initial adjustment.
- The clinician’s payment will be adjusted on the physician fee schedule monthly capitated payment for this group of patients.
Performance Payment Adjustment (PPA)
- This is a performance-based payment, either positive or negative for both ESRD facilities and managing practitioners, a fee-for-value or pay-for-performance model.
- For practitioners, the payment would be adjusted on the monthly capitated payment for managing dialysis claims, with some exclusions.12
Patients will be randomly assigned, based on new ESRD treatment starts, to 1 of 2 groups: the ETC arm and the conventional payment arm, where payments will not be affected. Those in the ETC arm, both facilities and providers, will be utilizing performance-based metrics and indicators.12
The HDPA will start at 3% in 2020 and gradually decline to 1% in 2022.13 The PPA will vary, with a potential upside gain of 5% and downward negative adjustment of up to 6% for the practitioner (slightly different for dialysis centers). Those in the ETC arm will also receive a payment of about $15,000 for transplants over the first 3 years of the transplant.13
In-center hemodialysis is a default modality for managing ESRD in the United States. The ECT model looks to break those barriers and increase the ESRD modalities of home therapies and transplantation to help improve outcomes and quality and control costs for this cohort of patients. The effect of this model will be evaluated in accordance with section 1115A of the Social Security Act to assess the quality of care furnished under the ETC model and changes in Medicare program spending. The evaluation will seek to determine whether the payment adjustments for managing clinicians and ESRD facilities under the model improves the uptake of home dialysis and transplants and reduces Medicare expenditures, while preserving or enhancing the quality of care for Medicare beneficiaries.
- US renal data system 2019 annual data report: epidemiology of kidney disease in the United States. Am J Kidney Dis. 2020;75(1, Suppl 1):S1-S64. https://doi.org/10.1053/j.ajkd.2019.09.002
- Flanagin EP, Chivate Y, Weiner DE. Home dialysis in the United States: a roadmap for increasing peritoneal dialysis utilization. Am J Kidney Dis. 2020;75(3):413-416. https://doi.org/10.1053/j.ajkd.2019.10.013
- Shukla AM, Bozorgmehri S, Ruchi R, et al. Utilization of CMS pre-ESRD kidney disease education services and its associations with the home dialysis therapies. Perit Dial Int. 2020;896860820975586. https://doi.org/10.1177/0896860820975586
- Mehrota R, Devuyst O, Davies SJ, Johnson DW. The current state of peritoneal dialysis. J Am Soc Neph. 2016;27(11):3238-3252. https://doi.org/10.1681/asn.2016010112
- Chan CT, Blankestijn PJ, Dember LM, et al; Conference Participants. Dialysis initiation, modality choice, access, and prescription: conclusions from a kidney disease: improving global outcomes (KDIGO) controversies conference. Kidney Int. 2019;96(1):37-47. https://doi.org/10.1016/j.kint.2019.01.017
- Dharod A, Bundy R, Russell GB, et al. Primary care referrals to nephrology in patients with advanced kidney disease. Am J Manag Care. 2020;26(11):468-474. https://doi.org/10.37765/ajmc.2020.88526
- Blake PG, Jain AK. Urgent start peritoneal dialysis: defining what it is and why it matters. Clin J Am Soc Neph. 2018;13(8):1278-1279. https://doi.org/10.2215/cjn.02820318
- Arya S, Melanson TA, George EL, et al. Racial and sex disparities in catheter use and dialysis access in the United States Medicare population. J Am Soc Nephrol. 2020;31(3):625-636. https://doi.org/10.1681/asn.2019030274
- Saran R, Robinson B, Abbott KC, et al. US renal data system 2018 annual data report: epidemiology of kidney disease in the United States. Am J Kidney Dis. 2019;73(3, Suppl 1):A7-A8. https://www.ajkd.org/article/S0272-6386(19)30009-5/fulltext
- Winkelmayer WC, Glynn RJ, Levin R, Owen Jr W, Avorn J. Late referral and modality choice in end-stage renal disease. Kidney Int. 2001;60(4):1547-1554. https://doi.org/10.1046/j.1523-1755.2001.00958.x
- Hundemer GL, Sood MM. Predialysis care and cardiovascular outcomes: why the lead up to dialysis matters. Kidney Int Rep. 2019;4(5):635-637. Published online: March 20, 2019. https://doi.org/10.1016/j.ekir.2019.03.010
- ESRD treatment choices (ETC) model. CMS.gov. Updated: December 29, 2020. Accessed: January 28, 2021. https://innovation.cms.gov/innovation-models/esrd-treatment-choices-model
- Wallace EL, Allon M. ESKD treatment choices model: responsible home dialysis growth requires systems changes. Kidney360. 2020;1(5):424-427. https://doi.org/10.34067/KID.0000672019