A new proposed rule that would expand Medicare coverage of dialysis services has already generated interest among skilled nursing operators, and multiple voices have called on officials to further cement the SNF connection.
The Centers for Medicare & Medicaid Services (CMS) in July rolled out the End-Stage Renal Disease (ESRD) Treatment Choices (ETC) model, a plan that would boost reimbursements for dialysis treatments and further encourage treatment of chronic kidney disease, the precursor to ESRD.
At the time, providers that specialize in mobile dialysis treatment trumpeted the proposal as a potential boon for nursing home operators: For the purposes of the rule, skilled nursing facilities count as “home” for residents, meaning SNFs could have a greater incentive and ability to offer dialysis services.
In addition, the new model could encourage operators to employ on-site nephrologists, expanding a skilled nursing facility’s specialties and potentially serving as a magnet for referrals in a given marketplace.
“There’s a lot of opportunity for CKD programs in nursing homes, but nobody wants to do it, because it doesn’t make money,” Shimmy Meystel, CEO of in-home dialysis provider Concerto Renal Services, told SNN over the summer.
But CMS received multiple letters that in part urged the government to do even more to foster better kidney-care outcomes in skilled nursing facilities during its open comment period on the proposed rule, which ended earlier this month.
Concerto, for instance, asked CMS to remove a restriction on covering dialysis services for seniors with dementia and acute kidney injury (AKI) as long as they reside in a skilled nursing facility. In the proposed rule, CMS exempted the former group due to AKI’s temporary nature and different treatment protocols, and the latter group because of concerns that in-home dialysis “may present an undue challenge” for elderly people with dementia.
However, Concerto argued that those issues are moot in a skilled nursing facility, where nurses and other staff members can provide the complex care that those conditions require. In addition, the need for such services will be great in the coming years: Concerto estimated that up to 45% of the growing cohort of skilled nursing residents with dialysis needs in 2025 will also be diagnosed with dementia.*
“Such an exception would incentivize onsite SNF ‘home’ dialysis to a patient population in need of such services, to their tremendous benefit,” Concerto executive vice president and general counsel Kyle Stone wrote in his letter to CMS administrator Seema Verma.
CommonSpirit Health, a non-profit Catholic health system, called on CMS to institute incentives for all types of health care providers — including skilled nursing facilities — to screen for CKD, with the eventual goal of increasing the prevention of ESRD.
“For example, could a nursing home provide the education, or an ambulance provider, or even a home health aide? We also recommend loosening the timeframe within which education can be provided,” Nicholas Stine, the health system’s senior vice president of population health, wrote in his letter. “We believe education about the risks of CKD, the progression of the disease, and the likely outcomes (i.e. dialysis, transplant) should be provided to patients with any stage of CKD.”
Stine also supported CMS’s decision to consider SNFs a resident’s “home” for the purposes of the payment adjustment.
“CommonSpirit recommends that CMS classify skilled nursing facilities (SNFs), inpatient rehab facilities (IRFs), and long-term care hospitals (LTCH) as a home dialysis site for patients that receive on-site dialysis while simultaneously receiving care at one of these facilities,” he wrote.
The public comments did reveal concerns about the timing of the new model, which would take effect January 1 should the rule be finalized. CommonSpirit, for instance, recommended that the new model take effect no earlier than April 1 and preferably July 1.
The Forum of ESRD Networks — an overarching advocacy group for kidney disease and transplant treatment — took that even further, asking CMS to delay implementation until January 1, 2021.
“Given this proposed timeline, dialysis facilities won’t learn that they are taking part in the ETC model until just prior to the proposed start date,” the organization wrote in its comments. “The proposed start date does not give dialysis facilities nearly enough time to prepare for this significant change in practice.”
*Editor’s Note: An earlier version of this story mischaracterized the number of residents projected to have dementia and require dialysis treatment. SNN regrets the error.