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CMMI Models, Part II: Increasing Home Dialysis
Those of us in the nephrology field are well aware of the serious health impacts and substantial costs of kidney disease. Now on the national stage, kidney disease is getting much-needed, overdue attention. The second in a series (following CMMI Models, Part I: Overview and What This Could Mean for Providers), this post outlines the Advancing American Kidney Health (AAKH) initiative’s goals and discusses what changes need to take place to reach the objective of increasing the use of home dialysis modalities.
AAKH goals and targets
The AAKH initiative seeks to improve kidney disease outcomes and reduce costs by advancing early chronic kidney disease (CKD) intervention, promoting home dialysis, and increasing kidney transplants by increasing the number of kidneys available. In terms of metrics, the initiative seeks to:
- Create a 25% reduction by 2030 in the number of Americans developing kidney disease
- Have 80% of new ESKD patients in 2025 either receiving home dialysis or a transplant
- Double the number of kidneys available for transplant by 2030
Increasing home dialysis
The AAKH’s goal to increase the number of patients using home dialysis modalities is based on substantial evidence that home dialysis delivers patients better health outcomes and a higher quality of life. However, currently approximately 10% of U.S. dialysis patients select a home modality. The use of in‑center dialysis has continued due to several factors, including a low level of provider and patient comfort and confidence with home modalities, patient and care partner burnout with home modalities, and peripheral barriers to home dialysis adoption.
In order to change the norm from in-center to home dialysis, broad-scale changes are needed in realigning payment models; encouraging greater awareness, education and training (among providers, patients and caregivers); and removing barriers to home dialysis adoption and sustainability.
- Payment models. The AAKH’s primary effort for increased home dialysis adoption lies in payment reform. The trial payment design, ESRD Treatment Choices (ETC) Model, aims to expand home dialysis (as well as transplant) by offering a bonus of up to 3% to nephrologists and dialysis providers who increase the number of patients receiving home dialysis. The model will include dialysis facilities and managing clinicians in select geographic areas; CMS will measure home dialysis rates each measurement year and adjust Medicare payments from 3% the first year to 1% the third year. However, the Performance Payment Adjustment (PPA) may decrease payment for dialysis and dialysis-related services based on a participating ESRD facility or managing clinician’s rate of home dialysis compared with other providers in the region.
- Awareness, education and training. While federal law requires clinicians to inform patients of all modality options, the need exists for greater awareness, education and training on home-based modalities, including daytime home hemodialysis, nocturnal home hemodialysis and peritoneal dialysis. Nephrologists and support staff, as well as patients and care partners, should be made aware of the benefits of home dialysis and be able to attend training that equips them to feel confident in home treatment. Although some dialysis providers and experts are taking steps to add or improve education on home dialysis, more needs to be done in this area.
- Barriers to home dialysis. One barrier to home dialysis adoption is the isolation and fear patients feel by being “on their own” with their treatment. Emerging technologies, such as telemedicine, remote monitoring, mobile apps, online courses, and risk analysis via artificial intelligence all offer ways to provide patients a greater sense of connection, comfort and confidence with dialyzing at home. Additionally, peripheral barriers, such as the costs associated with travel for training and setting up the home environment for dialysis, potentially difficult socioeconomic circumstances for patients and families in general, as well as burn-out barriers for both patients and caregivers, need addressing to make broad, long-term home dialysis adoption a reality.
The treatment of kidney disease and the infrastructure in which nephrologists provide treatment and receive payment has long needed reform. The United States lags behind several other countries with home dialysis rates of 20% or higher. The AAKH’s inclusion of home dialysis as a priority is the right first step to shine a spotlight and encourage growth of home dialysis, but the barriers mentioned, including payment models—as providers campaign for stronger financial incentives—need to be addressed in order for growth to be supported and successful.
Related information on increasing home dialysis from Dr. Schreiber was published in Nephrology News & Issues.