Just in time for Independence Day, CMS published a lengthy proposed rule on July 1, 2021, that, if implemented, will refine the mandatory ETC (End-Stage Renal Disease Treatment Choices) model just as we were all getting used to the initial rollout of ETC that went into effect Jan. 1. Succinctly titled “End-Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals with Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program, and End-Stage Renal Disease Treatment Choices Model,” the 345-page document covers a lot of terrain (mostly affecting dialysis centers).
But relevant to nephrology practices are a number of proposals for the ETC program. CMS is inviting public response, so for the policy wonks among you … it’s time to sharpen your pencils and let CMS know exactly what you think (and there is not much time … CMS is proposing to launch many of the changes as early as Jan. 1, 2022)!
On the positive side for many practices, CMS is proposing to:
- Exclude beneficiaries with certain vital solid organ cancers from the calculation of the transplant rate.
- Add nocturnal in-center dialysis to the calculation of the home dialysis rate (to incentivize the use of additional alternatives for renal replacement therapy).
- Improve attribution of living kidney donor transplant recipients to providers by attributing such patients to the managing clinician who submitted the most claims for services for the beneficiary in the 365 days prior to the transplant date.
- Allow kidney disease patient education services via telehealth (by waiving the geographic and site-of-service originating site requirements for ETC participants, even beyond the duration of the public health emergency).
- Allow ETC participants to reduce or waive beneficiary coinsurance for kidney disease patient education services, subject to certain requirements.
On the challenging side for many practices, CMS is proposing to:
- Increase the achievement benchmarks for the Performance Payment Adjustment (PPA) by 10% over rates observed in comparison geographic areas every two measurement years, beginning in 2022.
And on the innovative side, CMS is proposing steps to improve the equity of care in two specific ways:
- Stratify achievement benchmarks based on the proportion of attributed beneficiaries who are dually eligible for Medicare and Medicaid or receive the Low-Income Subsidy during the measurement year.
- Add a new Health Equity Incentive to the improvement scoring methodology for calculating the PPA (with the intent to decrease disparities in renal replacement modality choice in beneficiaries with lower socioeconomic status).
Lastly, on the transparency front, CMS is proposing a new mechanism to allow ETC participants timely access to reports and data. Specifically, if implemented, the data will provide beneficiary-identifiable information, including attributed beneficiary names, MBIs, dates of birth, dual-eligible status, LIS recipient status, AND
- number of months that the beneficiary was attributed to an ETC participant;
- number of months that a beneficiary received home dialysis/self-dialysis/nocturnal dialysis;
- number of months that a beneficiary was on a transplant waitlist; and
- number of months passed since the beneficiary received a living donor transplant.
A very large part of the proposed rule discusses the privacy and security implications of this proposed data sharing and the administrative and technical controls necessary for it to happen. But such sharing is arguably long overdue since the current ETC program does little to inform ETC participants about the details on which they are being measured (and having payments adjusted).
So, boom or bust? Hard to say. The answer will be in the details of the final rule when/if it arrives. But if past performance is any indication, we can likely expect that the broad themes of this proposed rule – equity, transparency, flexibility for beneficiaries – may appear in one form or another in future final rulemaking.
Timothy McNamara, MD, MPH is Sr. Director of Clinical Health IT in FMCNA Medical Office, and serves as Acumen’s Medical Director. Dr. McNamara is a physician with an extensive health informatics background. He brings 26 years of experience in healthcare IT from work in both corporate and academic environments.