The proposed changes mark a direct effort to close health equity gaps.

The Centers for Medicare & Medicaid Services (CMS) has proposed actions 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 rates. They are also more likely to experience higher hospital readmissions and costs, as well as receive in-center hemodialysis because their kidneys are no longer able to function. Studies also indicate that non-white ESRD patients are less likely to receive pre-ESRD kidney care, become waitlisted for a transplant, or receive a kidney transplant.

The proposed changes to the ETC Model build on the current system by proposing to test a new healthcare 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 said it 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, including information on race, ethnicity, Medicare/Medicaid dual-eligible status, disability status, LGBTQ+ status, and socioeconomic status. It also includes new methodological approaches to advance equity through the 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 percent of all dialysis facilities are reporting vaccination data performance to the Centers for Disease Control and Prevention’s (CDC’s) 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’s 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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