Friday, July 2, 2021

CMS Proposes Strongest Effort Yet to Directly Penalize Providers with Health Equity Disparities

Much has been written about socioeconomic and racial disparities in healthcare for decades.   Most Medicare policies did not address these directly.  Now, in the ESRD space, CMS is proposing measures that would directly penalize providers with ongoing disparities.   CMS notes that the effort is a direct collaboration between the regular ESRD policy makers and the Innovation Center (CMMI), which can waive certain laws for its own demo projects.


On July 1, CMS proposed annual ESRD rulemaking, and includes measures more directly targeting at health disparities than ever before.  Disparities in renal care include lower access to home dialysis and to transplants in low-economic and minority groups.

Historically, CMS has been highly aware of these and other disparities, but reluctant to address them directly.   For example - a hypothetical - CMS would be reluctant to require a white suburban hospital to have a 95% survival rate after a procedure, but an inner city hospital to have only an 85% survival rate.  However, by providing uniform reward and penalty benchmarks to such measures, inner-city hospitals might be perpetually penalized ad infinitum, further worsening their economic crisis year by year.

In the new ESRD rules, CMS writes, "[these] policies would aim to encourage dialysis providers to decrease disparities in rates of home dialysis and kidney transplants among ESRD patients with lower socioeconomic status, making the model the agency’s first CMS Innovation Center model to directly address health equity."

  • See press release here.
  • Fact sheet here.
  • Proposed rulemaking here.
  • See early coverage at Health Care Dive here.
The public has 60 days to comment, until circa September 1.

I've clipped part of the Fact Sheet below the break.  The model being adapted is the ETC, ESRD Treatment Choices model, which can inflict penalties or bonuses on providers based on home dialysis and transplant rates in their populations.

CMS Fact Sheet (Extract)

"...CMS is proposing changes to the ETC Model to address health and socioeconomic disparities, which are a major contributor to chronic kidney disease and ESRD. The proposed changes include incentives for participating ESRD facilities and Managing Clinicians to address health equity among their patients. They also include incentives that would reduce the disparities in which ESRD patients of lower socioeconomic status are able to access alternatives to in-center dialysis, specifically home dialysis and transplantation.

If these changes are finalized, the ETC Model would be the agency’s first CMS Innovation Center model to directly address health equity.

While people from all backgrounds can be diagnosed with ESRD, it is more common in minority and low-income populations. Social determinants of health impact not just who ends up with ESRD, but the quality of health care they are able to access. Closing these health equity gaps would help address this devastating disease, provide better accessibility to care, and reduce costs to the U.S. healthcare system.

CMS is considering a two-tiered approach to address disparities in home dialysis and transplant rates through the ETC Model’s benchmarking and scoring methodology.

  • CMS is proposing to add a Health Equity Incentive to the improvement scoring methodology for both the home dialysis rate and the transplant rate. With the Health Equity Incentive, ETC Participants who demonstrate significant improvement in rates of home dialysis or transplantation among their beneficiaries who are dual-eligible for Medicare and Medicaid or low-income-subsidy (LIS) recipients could earn additional improvement points.
  • CMS is also proposing to stratify achievement benchmarks by proportion of beneficiaries who are dual-eligible for Medicare and Medicaid or are LIS recipients, so ETC participants who see a high volume of these patients would not face negative financial consequences as a result.
Taken together, these two proposed changes acknowledge that socioeconomic disparities in access to alternative renal replacement modalities exist and may impact the ability of ETC Participants to perform well in the ETC Model, while providing an incentive for all ETC Participants to reduce such disparities among their Medicare patients...."