CMS Considers Policy Changes to Assess Home Dialysis Quality
Summary
A proposed rule issued by CMS has implications for the rapidly expanding home dialysis sector, including provisions for quality indicators such as home dialysis retention and a survey instrument for patient-reported experience.
CMS recently issued a proposed rule (CMS 1768-P) that furthers the mission of the agency to support one of its most vulnerable and costly populations: patients with end-stage renal disease (ESRD). In the proposed rule, CMS is looking to update Medicare payment rates under the ESRD Prospective Payment System (PPS) for dialysis services furnished to beneficiaries on or after January 1, 2023. Among the many topics covered in the proposed rule are quality indicators for the growing home dialysis sector, as part of much-needed updates to the ESRD Quality Incentive Program (QIP) and the ESRD Treatment Choices (ETC) Model.
Public comments for the proposed rule were due by August 22, with more than 250 letters submitted. This includes opinions from the National Kidney Foundation (NKF), that are highlighted here. A response from the agency is expected in early November.
Quality Indicators for Home Dialysis Patients
In this proposed rule for calendar year 2023, CMS cites its continued support of home dialysis, when appropriate, for both patients and the financial stability of the Medicare ESRD program. The agency writes, in part, “we are seeking comments on strategies to monitor and assess the quality of care delivered to patients who receive dialysis at home.”
CMS’ view is that while home-based dialysis may not meet the needs of every patient, it has clear benefits for those who are suitable candidates. The agency also points to research showing that survivability rates for home dialysis are comparable to those of transplant recipients and in-center hemodialysis, and that dialyzing at home is associated with lower overall medical costs than in-center treatment. “We believe that increasing rates of home dialysis has the potential to not only reduce Medicare expenditures, but also to preserve or enhance the quality of care for ESRD beneficiaries. In fact, recent studies show substantial support among nephrologists and patients for dialysis treatment at home,” says CMS in the proposed rule.
“At issue is that although some measures in the current ESRD QIP apply to in-center dialysis facilities, they do not generally apply to facilities that are managing high rates of home dialysis.”
At issue is that although some measures in the current ESRD QIP apply to in-center dialysis facilities, they do not generally apply to facilities that are managing high rates of home dialysis. This has led to many of these facilities being eligible for fewer ESRD QIP measures than facilities that provide in-center hemodialysis only. (The ESRD QIP is the first program of its kind in Medicare, that changes the way CMS pays for the treatment of patients who receive dialysis by linking a portion of payment directly to facilities’ performance on quality-of-care measures.)
As increasing numbers of ESRD patients opt for home dialysis, CMS is interested in learning more about potential indicators of quality of care for patients choosing to manage their own treatment at home, that are not currently being captured by the ESRD QIP.
NKF was among the many entities to submit public comments on this topic in the proposed CY2023 ESRD rule, with a multi-pronged, patient-centered focus on improving the home dialysis experience.
NKF’s Take on Home Dialysis Quality
As noted in its comment letter, NKF supports the development of home dialysis quality measures in the ESRD QIP that are relevant to patients managing their dialysis at home, including:
- Access
NKF says this should include patient-reported assessments of whether the individual was given a choice of modality, meaningful education on those choices and whether they are being treated with the modality they prefer. - Retention
According to NKF’s comment letter, a retention measure could help assess the quality of home training, that is one of the most important factors in a person’s ability to be successful on home dialysis. - Home Satisfaction
NKF mentions in its comment letter that CMS is considering a QIP measure of home dialysis satisfaction, perhaps based on the Home Dialysis Care Experience (Home-DCE) instrument developed at the University of Washington by Matthew Rivara, MD, and team. NKF’s position is that the Home-DCE is a good starting point, but currently does not capture outcomes or the patient experience. The goal of a home satisfaction measure should be to incentivize improved communication between the home patient and the care team. If the Home-DCE instrument is adopted by CMS, NKF encourages CMS to ensure the survey is provided on a timeline that allows the facility to make improvements and for patients to see that their feedback has been taken into account, thus encouraging patients to continue to want to engage in improving their care. - Quality of Life (QoL)
NKF comments that the patient-centered outcome that matters to home dialysis patients, in fact, all dialysis patients, is quality of life (QoL): “We acknowledge that quality of life is unique to each individual, is affected by processes outside of dialysis, and does not necessarily correlate with quality of care; developing accountabilities associated with QoL may be challenging. As a preliminary step, facilities could report an individual’s Activities of Daily Living (ADLs), which are much more closely related to an individual’s quality of life. There are also existing mechanisms that could be deployed to encourage nephrologists and providers to focus on QoL, for example better leveraging the Kidney Disease Quality of Life (KDQOL) tool that dialysis facilities must already administer to dialysis patients under the existing Conditions for Coverage, the development of the Plan of Care and the ESKD Life Plan.”
