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November 1, 2021

CMS Takes Decisive Steps to Reduce Health Care Disparities Among Patients with Chronic Kidney Disease and End-Stage Renal Disease

CMS is taking action to close health equity gaps by providing Medicare patients living with End-Stage Renal Disease (ESRD) with greater access to care. Through the ESRD Prospective Payment System (PPS) annual rulemaking, CMS is making changes to the ESRD Quality Incentive Program (QIP) and the ESRD Treatment Choices (ETC) Model, and updating ESRD PPS payment rates. The changes to the ETC Model policies aim to encourage dialysis facilities and health care providers to decrease disparities in rates of home dialysis and kidney transplants among ESRD patients with lower socioeconomic status, making the model one of the agency's first CMS Innovation Center models to directly address health equity.

"Today's final rule is a decisive step to ensure people with Medicare with chronic kidney disease have easy access to quality care and convenient treatment options," said CMS Administrator Chiquita Brooks-LaSure. "Enabling dialysis providers to offer more dialysis treatment options for Medicare patients will catalyze better health outcomes, greater autonomy and better quality of life for all patients with kidney disease."

According to CMS Office of Minority Health's studies on racial, ethnic and socioeconomic factors, disadvantaged people with Medicare have higher rates of ESRDExternal website. They are also more likely to experience higher hospital readmissionsExternal website and costs, as well as more likely to receive in-center hemodialysis (vs. home dialysis). 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.

CMS is improving access to home dialysis for patients of all socioeconomic backgrounds. For example, CMS is finalizing changes to the ETC Model to test a new payment incentive that rewards ESRD facilities and clinicians who manage dialysis patients for achieving significant improvement in the home dialysis rate and kidney transplant rate for lower-income beneficiaries. In addition, CMS is approving the first ever technology under a recently established policy that allows for enhanced payments for innovative technologies that represent a substantial clinical improvement relative to existing options. This approval will help ESRD facilities offer an additional option to beneficiaries for home dialysis at this critical time in the pandemic.

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. In response to the proposed rule, CMS received valuable feedback on potential opportunities to collect and leverage diverse sets of data such as race, ethnicity, Medicare/Medicaid dual eligible status, disability status, LGBTQ+ and socioeconomic status, to better measure disparities. CMS also received feedback on various methodical approaches to advance equity through the ESRD Quality Incentive Program (ESRD QIP). This valuable stakeholder feedback will help guide future rulemaking to improve health equity.

The rule finalizes policies for the ESRD QIP that address the circumstances of the COVID-19 public health emergency and functionality challenges relating to the implementation of a new data collection system. These challenges include a special scoring and payment policy under which no facility will receive a payment reduction under the ESRD QIP for the upcoming year, especially since such payment reductions would have been based on performance during the height of the pandemic in 2020.

CMS' proposed rule included several requests for information (RFIs) for the agency to consider as part of its goal to increase access to dialysis treatments at home. Commenters' responses to the RFIs included specific suggestions for improving Acute Kidney Injury (AKI) payment and the ESRD PPS.

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