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July 2, 2021

CMS Proposes Changes to Reduce Health Care Disparities Among Patients with Chronic Kidney Disease and End-Stage Renal Disease

Proposed changes mark Innovation Center’s first direct effort to close health equity gaps

CMS proposed actions that aim to close health equity gaps by providing Medicare patients battling End-Stage Renal Disease (ESRD) with greater access to care, through the ESRD Prospective Payment System (PPS) annual rulemaking. This proposed rule would update ESRD PPS payment rates, make changes to the ESRD Quality Incentive Program (QIP), and modify the ESRD Treatment Choices (ETC) Model. The proposed changes to the ETC Model policies would aim to encourage dialysis providers to decrease disparities in rates of home dialysis and kidney transplants among ESRD patients with lower socioeconomic status, making the model the agency’s first CMS Innovation Center model to directly address health equity.

According to CMS Office of Minority Health studies on racial, ethnic, and socioeconomic factors, disadvantaged Medicare patients suffer from ESRD at higher ratesExternal website. They are also more likely to experience higher hospital readmissionsExternal website and costs, as well as receive in-center hemodialysis because their kidneys are no longer able to perform their function. Studies also indicate non-white ESRD patients are less likely to receive pre-ESRD kidney careExternal website, become waitlisted for a transplant or receive a kidney transplant.

“Health equity is at the center of our work here at CMS,” said CMS Administrator Chiquita Brooks-LaSure. “Today’s proposed rule is grounded in measures to ensure people with Medicare who suffer from chronic kidney disease have easy access to quality care and convenient treatment options. When CMS encourages dialysis providers to offer more options for Medicare patients to receive dialysis treatments, it can be life changing and lead to better health outcomes, greater autonomy and better quality of life for patients with kidney disease.”

The proposed changes to the ETC Model build on the current model by proposing to test a new health care approach that rewards ESRD facilities and managing clinicians participating in the model for achieving significant improvement in the rates of home dialysis and kidney transplants for lower income beneficiaries. If finalized, these changes would take effect Jan. 1, 2022.

Consistent with President Biden’s Executive Order 13985 on Advancing Racial Equity and Support for Underserved Communities through the Federal Government, CMS is addressing health inequities and improving patient outcomes in the U.S. through improved data collection for better measurement and analysis of disparities across programs and policies. CMS is soliciting feedback in this proposed rule on opportunities to collect and leverage diverse sets of data. This includes race, ethnicity, Medicare/Medicaid dual eligible status, disability status, LGBTQ+ and socioeconomic status. It also includes new methodological approaches to advance equity through the ESRD Quality Incentive Program (ESRD QIP).

The rule includes proposals under the ESRD QIP to address the circumstances of the COVID-19 Public Health Emergency (PHE), such as not scoring or reducing payment to any facility in 2022 based on data from 2020. Regarding COVID-19 vaccination measures, the proposed rule requests stakeholder feedback on the feasibility of incorporating COVID-19 Healthcare Provider and Patient Vaccination measures in the ESRD QIP measure set. Currently, nearly 90% of all dialysis facilities are reporting vaccination data performance to the Center for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN). CMS is evaluating options for publicly reporting the data on official CMS datasets that compare the quality of care provided in Medicare-certified dialysis facilities nationwide.

CMS’ proposed rule includes several requests for information for the agency to consider as part of its goal to increase access to dialysis treatments at home. Currently, Medicare will only pay for dialysis at an ESRD facility for patients with Acute Kidney Injury (AKI). CMS is soliciting comments regarding potentially modifying the site of renal dialysis services for patients with AKI and payment for AKI in the home setting.

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