Oct 20, 2022
“We know that leaving the kidney disease health care system to its own devices, to do things by themselves for the good of patients, has just not worked. So if the major payer of kidney disease care is mandating improvements in the quality of care that would lead to better access and better equity in the system, hopefully that is going to be the lever that changes the system” -- Teri Browne, a University of South Carolina researcher who is looking into the disparities in kidney transplant access in the Southeast of the United States.
Chronic Kidney Disease (CKD) costs the healthcare system in the United States billions every year, and Medicare historically has shouldered most of the costs as they continue to be the entity, or Insurer that covers the majority of health care related to end-stage kidney disease. This of course includes dialysis, and this is where we now find Medicare, holding the proverbial carrot and stick to dialysis centers across the country.
One year ago, the Federal government rolled out a new plan to improve dialysis centers. A more aggressive approach with a target on the clinics bottom line, Medicare payments, if certain changes are not implemented. Changes that include the level of care patients get, choices as to dialysis options, and much needed help and guidance pursuing kidney transplantation. It's called the New End Stage Renal Disease Treatment Choices (ETC) model, and participation by dialysis clinics is not voluntary, it mandates that about 30% of the dialysis providers across the country participate. The other 70% are to be used as a control group.
The ETC model is a two part incentive plan on top of the already in place payment systems, and is being enacted in two phases. The first of the incentives began in 2021 and focused on increasing home dialysis use. The United States has recently seen home dialysis numbers start to rise from 6.8% in 2009 to 12.6% in 2019, though we still are far behind other countries in this area. Historically, the United States has prioritized dialysis done on site in a clinic, or center devoted exclusively to that purpose, and there have been financial incentives for providers to do so. Treating dialysis patients in the clinic made providers more money, so home dialysis as an option became a sort of afterthought when educating patients as to their choices regarding care. Today, the Federal Government has found home dialysis is a more affordable option for the healthcare system. Therefore, Medicare has an interest in seeing home dialysis grow in popularity and dialysis centers get a boost in payments for home dialysis use relative to in-center dialysis under the ETC model.
How do patients fare on home dialysis as compared to dialysis done in a center? Recent studies suggest patients do as well, or even better on home dialysis treatments. Some studies have shown patients do better and receive transplants quicker than patients receiving dialysis in a center. Home dialysis has the benefit of flexibility of schedule, with patients able to do treatments that fit into their individual schedule with work and family, instead of scheduling an appointment time according to treatment hours at a clinic. Studies also have shown home dialysis having a positive effect on patients' quality of life. However, there are patients who prefer to have dialysis done at a clinic or center. Some patients report wanting the separation between their home life and their medical treatments, keeping their home more of a sanctuary free of medical devices. However the patient chooses to have dialysis done, the point is that they are made aware that they have that choice, and are given all the necessary information on each option in order to make the right choice for them.,
The second part of incentives under the ETC model is payment increases, or decreases, dependent upon dialysis facilities performance in the areas of home dialysis, waitlisting patients for organ transplant, and living donor kidney transplantation rates, relative to control facilities.
In 2008, the federal government put into place a set of rules for dialysis centers. Centers were to follow the new rules in order to receive federal (Medicare) dollars. Those rules were to enforce communication between dialysis facilities and transplant centers. However we still find patients today have been left to attempt to navigate the system themselves, without communication or guidance. Terri Browne, a University of South Carolina researcher focusing on racial disparities in kidney transplants, says, “There are significant problems in ensuring dialysis facilities help patients to get transplants”. Through her research as part of The Southeastern Kidney Transplant Coalition she has interviewed dozens of dialysis patients, most of them African American, on their experiences, and says she hears “over and over again that patients are interested in getting a kidney transplant, but have not been given the information (or did not remember getting it), in order to pursue a transplant”.
“Even though dialysis facilities were required to educate patients about transplant options, the earlier Medicare mandate had no teeth to enforce the rule”, Browne said, “some dialysis facilities still report no patients on the transplant waitlist, and none or very few interested in receiving a kidney transplant”. She said this tells her that, “dialysis providers are still not doing enough to help patients navigate the system”.
Even those facilities that do strive to help patients to navigate through the complicated system of transplant waitlists, may fall short due to struggling with staff shortages and high numbers of patients. Through national surveys of dialysis patients and clinicians, Terri Browne and her colleagues found data stating that some Nephrology Social Workers are handling more than 200 patients at a time.
At year's end, Medicare will be sending out report cards to the facilities in the 30% mandated by the new ETC model. They will be notified of payment increases or payment reductions based upon the facilities performance in the previous year. How many patients are receiving home dialysis, how many patients are on transplant waitlists, or have had a kidney transplant and how many transplants were from a living donor? If the percentage rates look good, relative to comparable facilities in the control group, they will receive a payment boost. However, if your facility performs at a worse level than those in the control group, you may be seeing a reduction in payments.
“Medicare is moving toward a model of care that is more person centered”, said Rajnish Mehrotra, head of the Division of Nephrology at The University of Washington in Seattle. “I view this from a lens of patient empowerment. I think patients should choose the therapy that is best for them to have the life they want to live”.
The new ETC model is set to continue until 2026, when Medicare will decide whether or not to continue the program. If the model is successful, it could become the go-to payment model. Even if unsuccessful, the information gathered could still be very useful. It could fail due to insufficient incentives to change, or due to pre-existing challenges at a given facility, or other unforeseen factors. All of which should give better data to work with if the federal government should need to return to the drawing board in order to map out another model.
Monica McCarthy has bachelors in Political Science and Criminal Justice from Central Washington University. A majority of her career was spent as a political consultant. She currently works at KidneyLuv as a staff writer.
This material is for informational purposes only. It does not replace the advice or counsel of a doctor or health care professional. KidneyLuv makes every effort to provide information that is accurate and timely, but makes no guarantee in this regard. You should consult with, and rely only on the advice of, your physician or health care professional.