ESRD Hemodialysis Hits Home with the New ETC Model

March 16th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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With at-home dialysis usage rates in the United States about 12% below other countries, the Centers for Medicare and Medicaid Innovation (CMMI)is focused on the goal of improving this deficiency through a new alternative payment model, referred to as the End Stage Renal Disease Treatment Choices (ETC) Model. The ETC Model includes mandatory participation by about 30% of all End Stage Renal Disease (ESRD) facilities and ESRD managing clinicians (physicians and NPPs). It will be incentivized in an effort to promote at-home dialysis and health equity for transplant recipients with socioeconomic disparities. The goal is to increase at-home dialysis services through educating patients on at-home dialysis, as an alternative option to in-center dialysis, which would reduce costs and improve transplant wait-list times. Prior to implementation of the ETC Model, there were more incentives for nephrologists to perform in-center dialysis rather than at-home dialysis for two main reasons: 

  1. ESRD facilities can see more patients per dialysis machine by seeing them in a dialysis center.
  2. In-center hemodialysis has been the default form of dialysis for so long, that many do not realize the option is available for at-home dialysis.

CMMI hopes that the combined efforts of multiple programs, such as the Medicare Part C ESRD Risk Adjustment Model and the ETC Model, will improve access to at-home dialysis and reduce wait-list times for transplantation.

The ETC Model became effective as of January 1, 2021 and will end on June 30, 2027. Selected participating facilities and providers will be determined by zip code and the geographic location where most of their ESRD patients are treated. Participating providers may be eligible to receive financial incentives between 2021-2023, which are intended to incentivize them to develop the infrastructure of at-home dialysis and hopefully improve wait-list times for receiving donor organs, in an effort to improve transplant equity.

There are two types of payment incentives: 

  • Home Dialysis Payment Adjustment (HDPA), which provides a bonus payment on the monthly capitation payment (MCP)for Home Dialysis for the first three years of the program, at 3% for 2021, 2% for 2022, and 1% in 2023.
  • Home Dialysis and Transplant Performance Assessment and Performance Payment (PPA), is a bit more complicated and includes both positive and negative aspects governing payment incentives. This payment incentive is slated to grow in magnitude between 2021 and the end of the program in 2027.

In order to be eligible for payment increases and to avoid payment reductions, participants must achieve and/or improve on their at-home dialysis and transplant wait-list times. With benchmark rates already established, the first measurement year began in 2021 and Medicare will adjust claims for the first time in the second half of 2022. At-home dialysis rates will be weighted twice as much as transplant rates for modality performance scoring purposes, and while the at-home dialysis services will not risk adjust, CMS will 'risk adjust' the transplant wait-list. 

Another impressive development is the End-Stage Renal Disease Treatment Choices Learning Collaborative (ETCLC), which was created by CMS and Health Resources & Services Administration (HRSA). The program has three main goals for ETC model participants, which are:

  • Increase the number of deceased donor kidneys transplanted
  • Decrease the national discard rate of all procured kidneys
  • Increase the percentage of change for kidneys recovered for transplant in the 60-85 Kidney Donor Profile Index (KDPI) score group

These are some pretty big changes for the ESRD community and the risk-benefit ratio is high for all involved. Take the time now to learn more about the ETC Model program and ETCLC by reviewing the listed References.


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