On October 29, 2021, CMS published a final rule updating the ETC (ESRD Treatment Choices Model) that went into effect on January 21, 2021. And the changes in the new rule go into effect soon—on January 1, 2022.
The most jarring provision is an increase in 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—an increasing hurdle that will certainly represent an ongoing challenge for practices.
Beyond the change to future achievement benchmarks, the new rule otherwise mostly sands the edges of the current ETC program, with provisions focused on a key theme: decreasing socioeconomic disparities and improving health equity.
To do so, CMS is creating a new Health Equity Incentive that will allow ETC participants to earn additional improvement points to increase their MPS (Modality Performance Score)—the score that drives the PPA and success in the ETC program.
To identify patients who may have lower socioeconomic status for purposes of this incentive, CMS will use two proxies to flag patients: those who are either dual-eligible for Medicare and Medicaid or those who receive the Low Income Subsidy (LIS), a subsidy available for Medicare patients who require assistance with the costs of Medicare prescription drug coverage.
Specifically, improvement in home dialysis rates or transplant rates for dual-eligible patients or patients receiving the LIS can result in improved MPS and improved payment adjustments. CMS is looking for a 2.5 percent or greater increase in the home dialysis rate for such patients, which will result in a 0.5 point increase in the ETC participant’s home dialysis rate improvement score. Similarly, CMS is looking for a 2.5 percent or greater increase in the transplant rate for such patients, which will result in a 0.5 point increase in the ETC participant’s transplant rate improvement score.
CMS will also stratify achievement benchmarks so that ETC participants who care for a high volume of dual-eligible or LIS recipient patients are not disproportionately negatively affected.
On a positive note, CMS has made NO changes to the Home Dialysis Payment Adjustment (HDPA) (the upside bonus for every home therapy MCP claim paid by CMS—set at 2% for 2022 and 1% for 2023).
Other provisions of the final rule include:
- Exclusion of beneficiaries with certain vital solid organ cancers from the calculation of the transplant rate
- Addition of nocturnal in-center dialysis to the calculation of the home dialysis rate (to incentivize the use of additional alternatives for renal replacement therapy)
- Improved 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
- Allowing 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)
- Allowing ETC participants to reduce or waive beneficiary coinsurance for kidney disease patient education services, subject to certain requirements
Another useful provision of the Final Rule is that CMS will begin to share beneficiary-identifiable data with ETC participants who request it beginning as early as June 2022. Such data will include, when available, attributed beneficiaries’ names, Medicare Beneficiary Identifiers, date of birth, dual-eligible status, LIS-recipient status, the number of months the beneficiary was attributed to the ETC participant, home-dialysis months, self-dialysis months, nocturnal in-center dialysis months, transplant waitlist months, and months following a living donor transplant. CMS aims to provide these data at least one month before each PPA period via a web-based mechanism that will require a signed data-sharing agreement with ETC participants and provisions to protect the privacy and security of beneficiary data.
(Throughout 2021, Acumen and Fresenius strongly advocated for such data sharing because we believe it provides opportunities for practices to have greater visibility into important patient characteristics—like transplant list status—that are not always easily or accurately obtained and for practices to have greater transparency into the data on which CMS measures ETC success. We are especially pleased to see that CMS agreed and will be providing such data for practices that request it.)
One other small bit of good news. The new final rule will require no new administrative burden on practices. All of the changes will go into effect “behind the scenes” using data that CMS already collects from claims and other sources. Thus, the roll-out of the changes should have limited discernable effects on day-to-day practice workflows.
Bottom line: The mandatory ETC program remains a challenging one for practices that have been selected to participate in it, and it will only get incrementally more challenging under the new final rule as achievement benchmarks increase. The new Health Equity Incentive may provide some relief for practices that are able to take advantage of it. And at some point, practices may have much greater visibility into the details underlying the program, which should increase opportunities for success.
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.