Currently, there is $410 billion of unmanaged kidney disease spend in the U.S. annually. According to the Centers for Disease Control and Prevention (CDC), 90% of people with chronic kidney disease (CKD) are not aware they have it. Even more troubling is how CKD disproportionately impacts people of color.
Health equity is a significant issue among people in the later stages of kidney disease, including end-stage renal disease (ESRD). Although ESRD can affect anyone, it’s more common in marginalized communities. Black/African Americans are nearly four times more likely to develop kidney failure compared to White Americans. Latinos are 1.3 times more likely to experience kidney failure.
Underserved populations are also less likely to receive quality care for their disease. With limited access to optimal treatments, they experience higher hospital readmission rates ¾ and the Covid-19 pandemic has exacerbated these inequities.
According to the Centers for Medicare & Medicaid Services (CMS):
- While Black/African American people make up 7.5% of all Medicare beneficiaries who are 65 or older, they make up 33% of Medicare beneficiaries with CKD, followed by American Indian/Alaska Native (30%), Hispanic (28%) and Asian/Pacific Islander (26%). White (23%) beneficiaries had the lowest percentages of CKD.
- Hospital outpatient spending, which includes dialysis treatments, was highest within underserved patients with ESRD.
- The average Medicare hospital outpatient spending was 5-12% higher for 65-and-older diverse populations with ESRD compared to that of White ESRD patients of a similar age.
- The 30-day readmission rate for 65-and-older Black/African Americans with ESRD is 19% higher than the readmission rate for similarly aged non-Hispanic White Americans with ESRD.
Rising obesity and diabetes rates are also elevating the prevalence of kidney disease, and statistics show minority and low-income populations are disproportionately at risk for this chronic condition. In his blog, Dr. Bruce Quinn writes: “Social determinants of health impact not only those who end up with ESRD but also the quality of health care they can access. Closing these health equity gaps would help address this devastating disease, provide better access to care and reduce costs to the U.S. healthcare system.”
These disparities are related to the patient, clinical and systemic factors that are in our control to fix. Thankfully CMS is finally bringing health equity into the equation with its proposed changes to close racial disparity gaps ¾ and it’s about time.
CMS Proposed Health Equity Changes
CMS has recently proposed essential and timely reimbursement changes to close the racial discrepancy gap around the mandatory payment model for kidney disease. The rule proposes alterations to the ESRD Treatment Choices (ETC) Model to encourage healthcare providers to bring the rates of home dialysis and kidney transplants among ESRD patients with lower socioeconomic status in line with others, making this the first CMS Innovation Center model to directly address health equity.
These revisions are consistent with President Biden’s Executive Order 13985 on Advancing Racial Equity and Support for Underserved Communities by leveraging technology and feedback to evaluate data and implement systems that consider race, ethnicity, Medicare/Medicaid dual-eligible status, disability status, LGBTQ+ and socioeconomic status. Also included are new methodological approaches to advance equity through the ESRD Quality Incentive Program.
Advancing racial equity and supporting underserved communities is paramount. The proposed changes could address health and socioeconomic disparities, which account for more than 33% of CKD and ESRD cases.
Multi-Faceted Approach to Addressing Disparities
The proposed CMS changes involve a two-tiered approach that would benefit both providers and people with late-stage kidney disease. First, there is an added health equity incentive to improvement scoring. Under the current ETC Model, participating providers are rewarded for increasing their population of patients who receive home dialysis or transplants. The proposed changes would add a scoring incentive to care for patients who are dual-eligible or Medicare patients receiving a low-income subsidy. Providers who can show positive outcomes in treating lower-income patients, either on home dialysis or with a transplant, could earn additional points.
The second part of the two-tiered approach stratifies achievement benchmarks based on patient make-up, assessing provider performance against benchmarks set by comparable nephrology practices not in the ETC Model for home and in-center dialysis claims. More under-represented individuals will have improved access to alternative kidney replacement treatments, including home dialysis which often leads to better health outcomes, greater patient autonomy and improved quality of life.
Adjusted benchmarking based on patient populations helps participants focus more on providing care and less on possible financial penalties, translating into better outcomes and quality of life for individuals.
These incentives encourage participating facilities and managing clinicians to address health equity among their patients. Most importantly, the changes incentivize providers to assist ESRD patients of lower socioeconomic status to access alternatives to in-center dialysis, specifically home dialysis and transplantation.
Health disparities are not new. Commercial insurers typically follow CMS’ lead, which will build on this momentum. Although these changes are taking the necessary steps, more needs to be done — both related to and beyond kidney care. Healthcare organizations can now address health equity through several approaches, including home-based care that takes social determinants of health into account and encourages facilities to treat lower-income patients.
In addition to the flexibility that home-based care can provide when available, artificial intelligence (AI) algorithms can identify patients sooner, including some people who may slip through altogether, allowing the opportunity for programs and early interventions that may delay treatment needs. This comprehensive look at the patient is especially helpful for people without a stable address or regular physician. Data gathered from a broad spectrum of providers can be fed into the algorithm and identify patients sooner, delivering a more complete picture.Care must be taken in developing AI algorithms to ensure bias is not introduced. Done correctly, these tools have the opportunity to identify and even reduce disparities.
As with all first steps, expect more to come. Kidney disease is experiencing a wave of innovation that is expected to bring new standards that can be applied to other chronic conditions in the future and make care more equitable in the process.
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