Payment approaches to addressing health equity are seen in a new Medicare rule for kidney care

Updates to a CMMI model for ESRD care include an equity-related bonus payment and changes to benchmarking.

Changes to a pilot model for kidney care indicate the types of approaches CMS likely will use to make equity a cornerstone of Medicare payment policy.

The agency recently published a white paper in which it spelled out the changes it will apply to value-based payment models. Promoting equity is one of the strategic pillars detailed in the paper.

The 2022 final rule for the End-Stage Renal Disease (ESRD) Prospective Payment System includes updates designed to advance that goal. Relevant changes specifically are part of the ESRD Treatment Choices (ETC) Model, which debuted this year as a program of the Center for Medicare & Medicaid Innovation (CMMI).

The six-year model, which is mandatory for ESRD facilities and managing clinicians in certain geographic areas, was designed to increase the use of home dialysis and transplantation and decrease rates of in-center hemodialysis for Medicare beneficiaries with ESRD.

As implemented for 2021, the model includes payment increases for providing home dialysis and related services through 2023. The ’21 rule also established that beginning for services provided in July 2022, payments can be increased or reduced based on rates of home dialysis and transplantation for attributed beneficiaries.

A more targeted approach to equity

A CMS news release on the 2022 final rule for the ESRD PPS alluded to data from the agency’s Office of Minority Health regarding gaps in kidney care access and outcomes. The office found that “disadvantaged people with Medicare have higher rates of ESRD. They are also more likely to experience higher hospital readmissions 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 care, become waitlisted for a transplant or receive a kidney transplant.”

The update for 2022 is designed to address those disparities more directly. Providers can boost their payments by demonstrating improvement in the home dialysis rate or transplant rate among attributed beneficiaries who are dual-eligible for Medicare and Medicaid or are low-income subsidy (LIS) recipients.

In addition, CMMI will stratify a provider’s achievement benchmarks by the proportion of beneficiaries who are either dually eligible or LIS recipients. The goal is to ensure that providers seeing a high volume of those patients are not disproportionately affected based on the original benchmark methodology.

“Taken together, these two changes acknowledge that socioeconomic disparities in access to alternative renal replacement modalities exist and may impact the ability of ETC participants to perform well in the ETC Model, while providing an incentive for all ETC participants to reduce such disparities among their Medicare patients,” CMMI stated.