Health Reform WK-EDGE CMS rolls out new mandatory payment model for ESRD treatment
Thursday, October 1, 2020

CMS rolls out new mandatory payment model for ESRD treatment

By Cathleen Calhoun, J.D.

Who will participate in the ESRD treatment choices (ETC) model, what are the benefits, and how long will it last?

A new end-stage renal disease (ESRD) treatment choices (ETC) model is finalized as a mandatory payment model for those chosen to participate, with the goal of encouraging greater use of home dialysis and kidney transplants for patients with chronic kidney disease (CKD). CMS describes it as an innovative payment model that aims to test if the greater use of home dialysis and kidney transplantation for Medicare beneficiaries with ESRD will reduce Medicare expenditures, while at the same time, sustaining and improving the quality of care. In an advance release of a final rule, CMS estimates that the savings as a result of the new model will equal $23 million over five and a half years. Certain payments will by adjusted to ESRD facilities and nephrologists and other clinicians managing beneficiaries with ESRD (Managing Clinicians) that are selected to participate in the new ETC model.

Selection process. ESRD facilities and managing clinicians will be chosen to participate in the model based on their location, in randomly selected geographic areas. The group will be about 30% of adult ESRD beneficiaries, with all 50 states and the District of Columbia represented. Medicare payments will go on as usual for ESRD facilities and Managing Clinicians not selected to participate. ESRD facilities and Managing Clinicians in Maryland would generally be included in the model’s interventions to provide consistency with the Total Cost of Care Model being tested in the state of Maryland. Those facilities and clinicians serving low volumes of adult ESRD beneficiaries will be excluded.

Timeline. Medicare payment adjustments for the ESRD facilities and Managing Clinicians selected to participate in the ETC model will apply to certain Medicare claims from January 1, 2021, through June 30, 2027. CMS is requiring participation for those chosen.

Payment adjustments. According to CMS, the ETC model will explore changing Medicare payments from traditional fee-for-service payments to payments where providers are given an incentive to encourage patients receiving home dialysis and kidney transplants. The ESRD ETC model has two types of adjustments: (1) a positive adjustment on Medicare claims for home dialysis and home dialysis-related services during the initial three years of the model, providing an additional payment to selected ESRD facilities and managing clinicians for supporting beneficiaries with dialysis at home, and (2) a second adjustment for both home and in-center dialysis and dialysis-related claims. The second adjustment could be either positive or negative. The upward or downward adjustment would be made to the per treatment payment for dialysis based on the rate of home dialysis and transplant rate calculated as the sum of the transplant waitlist rate and the living donor transplant rate. Transplant waitlisting means a beneficiary becomes eligible to get a kidney when one becomes available at the beneficiary’s transplant center.

Medicare benefit enhancements. Under the new ETC model, CMS is conditionally waiving certain requirements for the Kidney Disease Education (KDE) benefit to allow additional types of practitioners to furnish services. Currently, Medicare covers up to six 1-hour sessions for beneficiaries with stage 4 chronic kidney disease (CKD), but only with certain types of clinicians.

The model will go into effect January 1, 2021.

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