CMS ETC Payment Model and Dialysis Preference and Transplant Incidence

Kidney Week 2020

The Centers for Medicare & Medicaid Services End Stage Renal Disease (ESRD) Treatment Choices (ETC) Model will begin on January 1, 2021. The ETC is a mandatory payment model that assigns financial bonuses and penalties to dialysis facilities as a function of home dialysis prevalence and the incidence of kidney transplantation among patients with Medicare fee-for-service coverage.

Kristine Kubisiak and colleagues conducted an analysis using claims data to estimate distributions of facility-level dialysis prevalence and incidence of kidney transplantation. Results of the analysis were reported during a virtual poster session at ASN Kidney Week 2020 in a poster titled Home Dialysis and Kidney Transplant Assessments in the ESRD Treatment Choices Payment Model.

The analysis included data from Medicare Limited Data Sets, used to identify all Part B claims for outpatient dialysis for the treatment of ESRD in 2017. The researchers estimated the percentage of patient-months with any home dialysis treatment in each dialysis facility with ≥132 adult patient-months. Part A 2017 claims were used to estimate the number of kidney transplants among dialysis patients in each facility.

The analysis identified 6263 dialysis facilities representing 3,645,655 patient-months. Overall prevalence of home dialysis was 10.8%. The analysis revealed three features regarding the distribution of facility-level home dialysis prevalence: (1) more than 54% of facilities has exactly 0% home dialysis prevalence; (2) among facilities with any home dialysis utilization, there was a unimodal distribution with peak prevalence near 12%; and (3) a small subset of facilities (4%) had home dialysis prevalence >90%.

More than half of the facilities had one or more kidney transplant. The 75th and 90th percentiles of transplant count were 2 and 4, respectively.

In conclusion, the researchers said, “In patients with Medicare fee-for-service coverage, facility-level dialysis prevalence exhibits a nonnormal distribution, while kidney transplant incidence typically manifests few (or no) events per year. Both patterns will complicate statistical analysis of performance in the ETC model. Alternative methodology should consider assessments in regional clusters of facilities.”

Source: Kubisiak K, Weinhandl ED, Dalrymple Ls, Kossmann RJ. Home dialysis and kidney transplant assessments in the ESRD Treatment Choices Payment model. Abstract of a poster presented at the American Society of Nephrology virtual Kidney Week 2020 (PO1242), October 22, 2020. Funding for this poster was supplied by Fresenius Medical Care.