Skilled Nursing Residents Shut Out of New End-Stage Renal Disease Payment Model

The Centers for Medicare & Medicaid Services (CMS) on Friday announced the finalization of a new kidney-care payment rule, but the regulation specifically exempts patients who are receiving their dialysis treatment in the nursing home.

The End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model is intended to test whether greater use of home dialysis and kidney transplantation for Medicare beneficiaries with ESRD can lower the program’s expenses while maintaining or improving their quality of care.

But it draws from a specific pool of beneficiaries: those receiving care from health care providers participating in the ETC model.


“In determining the home dialysis rate and the transplant waitlist rate and living donor transplant rate for participating ESRD facilities and Managing Clinicians for purposes of the performance payment adjustments, certain beneficiaries will be excluded, including those under age 18, in hospice, in nursing homes or skilled nursing facilities, diagnosed with dementia, and receiving dialysis for acute kidney injury only,” the fact sheet on the new model said.

While the ETC has been in the works since last summer, CMS framed the promotion of in-home dialysis could serve as a bulwark against the spread of COVID-19.

“The current Medicare payment system and a lack of beneficiary education may encourage in-center hemodialysis as the default treatment for patients beginning dialysis,” CMS observed in a press release about the model. “Having to travel to dialysis centers for their treatment also potentially exposes those with ESRD to illnesses like COVID-19.”


Indeed, these centers have emerged as a potential vector of infection for nursing home residents amid the COVID-19 pandemic.

But according to officials on a national stakeholder call held on September 18, nursing home patients are being exempted from the ETC model.

“Our thought there is just in recognition of the unique set of circumstances that are facing nursing home patients,” an official said on the Friday call. “We didn’t want to them to be included in the incentives in either the numerator or the denominator of the model. As a result, they are exempted from any positive or negative incentives, in recognition of their unique circumstances and in recognition of the efforts that nursing facilities have to do to install the infrastructure to deliver dialysis in person or deliver a form of home dialysis.”

Stakeholders had lobbied CMS both for and against the inclusion of nursing home residents in the model, which when initially proposed raised dialysis providers’ hopes of expanded coverage in the setting; in response, the federal government decided that covering SNF patients would not align with the overall goal of increasing transplant rates.

“We share the commenters’ concerns about dialysis provided in SNFs, particularly around the misalignment of dialysis utilization in SNFs and nursing facilities with the Model’s focus on promoting beneficiary choice of treatment modality,” CMS observed in the final rule. “In addition, CMS is concerned that the population of beneficiaries who reside in SNFs and nursing facilities is particularly frail, including beneficiaries diagnosed with dementia, and therefore may not be appropriate candidates for home dialysis.”

The ETC — which will take effect on January 1 and run through June 30, 2027 — will provide supplemental payments to ESRD treatment providers that offer in-home dialysis treatments, with the goal of encouraging investment in the models and keeping patients out of the hospital.

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