Is End-Stage Renal Disease Treatment Choices Model Moving the Needle?

A recent JAMA Health Forum study found that the Centers for Medicare & Medicaid Services’ End-Stage Renal Disease Treatment Choices (ETC) alternative payment model showed no statistically significant impact on the use of home dialysis or kidney transplant rates. Healthcare Innovation recently discussed the study with Amit Kapoor, M.D., chief nephrologist at Strive Health, a value-based care company focused on kidney disease. 

Healthcare Innovation: Before we start talking about CMS’ ETC model and this study, could you describe your background and role at Strive? 

Kapoor: I am a board-certified, practicing nephrologist. I started out in private practice in 2006, in a small group based in Darby, Pa. I was responsible for merging our practice with a larger group in the area, so we became a large nephrology group and my role evolved in the practice to take on more of a management role and I got my M.B.A. Then I started working closely with DaVita on their value-based care model. This opportunity came along with Strive in 2021 to lead provider relationships. We've expanded our footprint to over 700 nephrologists throughout the country, working with us on CKCC [Comprehensive Kidney Care Contracting] and other value-based contracts. I oversee that from a clinical lens. As the chief nephrology officer, I work on the provider integration, provider engagement, customer success, really supporting our practices to drive best outcomes.

HCI: This study in JAMA Health Forum found that there was no statistically significant difference in the use of home dialysis or kidney transplant between regions randomly assigned to the ETC model vs. those in control group regions. Can you talk about whether that's surprising or disappointing, or were there things about the design of the model that might explain that?

Kapoor: As a North Star goal, you want to increase transplant rates and you want to increase home dialysis penetration. I think the premise of the model and the goals of the model were obviously well-intentioned. I would argue that the model did have some success in a couple of ways. One is that we did see a change in behavior. We did see an overall increase in home penetration rates. We saw everything rise slightly, about 2% right across the board. So it's one of those high-tides-lifts-all-boats type of thing. For instance, in the dialysis units, there is more of this push to get them out of the chair and into the home environment, or even to transplant. So I think that's the positive. 

Also, with this type of initiative, where we've had decades of practicing the same way, you're not going to see in two or three years a massive shift. The dialysis unit is approaching it in a different way. Whereas they previously looked at it, unfortunately, from a financial standpoint. Reimbursements are better if you keep patients in the chair.  What’s important, though, is the foundation. We’re talking to our patients earlier about the process. Our patients are getting a better understanding of the options.

Although transplant rates are not up, we are seeing a greater push to transplant. We are seeing an increase in patients who are engaged and activated and want to learn about transplant. So I think the pipeline is filling up quicker and is more robust than it may have been three or four years ago.

HCI: There was a story in Healio that described this study and ran a commentary alongside it by Eugene Lin, M.D., M.S., a professor at the USC Schaeffer Institute. I am hoping we can go over a few of the points he made and get your reaction. For one, he said that this ETC model was one of the first randomized trials run by CMMI, and so that, in itself, could yield information about the efficacy of financial incentives for nephrologists.

Kapoor: This is the first randomized trial. We can look at the depths of the inequity or healthcare disparities by looking at this randomized trial. In other words, who was educated, who was not? Did demographic characteristics factor in to driving better outcomes? How we educate patients, how we talk to patients, patients’ preferences, the barriers for patients. So I do think this trial could lead to a lot of pertinent information in terms of where we saw the increases and where we didn't, and how much of a role did the financial incentives play in perhaps driving some of that behavior or were the incentives enough? Or is this too early in the process to make a definitive conclusion on the incentives? 

HCI: Dr. Lin mentioned two other things that he said might have had an impact on results during this timeframe: COVID and the opening of Medicare Advantage to patients with ESRD. He said CMMI might have to figure out what impact those things had on the model. 

Kapoor: I agree 100 percent. With Medicare Advantage, you’re seeing almost 20 to 30% churn year over year. Part of that, obviously, is patients passing away, patients moving out of the area, but also a large percentage is patients changing plans. So this proliferation in MA plans, where you are going up to 30 to 35% MA plans in some markets, is going to have a huge impact on patient behavior. 

Likewise, COVID obviously disrupted our entire healthcare system. For some of our patients, COVID pushed them toward home from a dialysis center where you’ve got 20 to 30 patients lined up in a chair; doing it at home was safer for patients. So I think that's a positive for some. In other ways it was a negative, because you lost that personalized training. You lost the ability to have multiple touch points to educate patients and support patients as they transition, especially to home. And obviously it shut down transplants for an extended period of time as well. So I think COVID definitely affected our metrics in a lot of ways, and also the way we provide clinical care.

HCI: Dr. Lin also said that CMS needs to consider whether future models should have a similar randomized design. Do you have thoughts about that? 

Kapoor: I do. This goes back to my concerns about the ETC model in terms of health inequity. Part of the randomization is great, but you also have to understand that there are already built-in intrinsic barriers that limit the success of some of our populations. In certain demographic areas where the natural rate of home penetration is much lower, partly because of the education that's provided to the patients, partly because of housing barriers, the financial inability for patients to connect with their providers, pre-dialysis, in terms of understanding and giving them the adequate amount of education to support. So while I like randomized trials, I do think we need to take into account these built-in barriers that exist in our population.

HCI: The ETC model did have a health equity incentive built in, right?

Kapoor: It did, but I don't think it went far enough, because where we've seen units that were traditionally very low in terms of home penetration or transplant, they remained fairly low because of those intrinsic barriers. With  things like staff-assisted dialysis support in the home, if you didn't have internet access, how are you able to communicate with the patient at home via telehealth? So there are various things that we don't account for as providers that make a huge impact, from a patient perspective.

HCI: Are there things about the clinical workflow or the way the financial incentives line up that have hindered growth in transplant rates?

Kapoor: To me, the biggest barrier in transplant is just the entire process of getting a patient from referral to a transplant center and then the next steps, right? You get the initial evaluation done, and it's a pretty lengthy process to get active on a list in terms of the pre-operative testing and labs that are needed, and all the different consultants that are required to get a patient active. So that's a pretty laborious process for a patient, and the communication still isn't there. We still don't have that EMR integration, or that systems link-up, so the nephrologist, primary care physician, or dialysis units are aware of what is happening. Oftentimes what will happen is patients will miss appointments, things will get missed, and it puts the patient back at square one. So I think there's still a siloed component to the whole process of transplant, aside from the financial incentives. 

HCI: Broadening out a bit in terms of CMMI, do they have to consider making more of their alternative payment models mandatory? 

Kapoor: That is a good question. I do think we're going to get to a point where it becomes mandatory. About 13.5% of Medicare patients are diagnosed with CKD and a lot more probably have it and are undiagnosed. We are going to see those numbers go up on the ESRD side. There, 1% of the population is driving about 8% of the cost. So I definitely think CMS is moving to a point where it becomes mandatory. 

Right now, maybe 20 to 25% of how a practice operates is in a value-based care model. I think over the next five or six years, it'll probably be 60-plus percent in a VBC model where they're getting paid through incentives. 

But CMS needs to protect the practices. The biggest thing that hurt us last year was the retrospective trend adjustment, where essentially CMS said because of COVID utilization, benchmarks were a lot lower than we previously anticipated. So even though you thought a benchmark was x, we are actually lowering it by $10,000 which dramatically impacted the potential for shared savings and also shared loss. I think CMS has to make sure there are not these last-minute changes. If there are, there have to be safeguards to protect practices, because we do operate on thinner financial margins, so we don't have the capacity to adjust to these huge changes. 

I do think practices will be obligated to be in it. But what we might see is some variation in terms of shared risk and shared savings. When you change a model and say it's mandatory, but there's going to be shared risk as well as shared savings, with safeguards, I think it forces not just the leadership of practices, but the physicians to buy in. What we’ve seenn historically is that leaders buy in, but the everyday clinician still doesn't get it. Now, when you go to a physician and say, ‘Hey, not only can you make $20,000 more per year, but you could lose $20,000 to $30,000,’ that changes the mindset and gets more buy-in.

This is where Strive comes in, because if it is going to become mandatory and this is how you are going to be evaluated, now there's real financial skin in the game, and you need a partner that has all the tools to help you be successful.