Proposed Changes Aim to Reduce Health Disparities Among ESRD Patients

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August 4, 2021

By Dr. Shika Pappoe, Chief Medical Officer

Health equity is a significant issue among people with 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. Hispanics and Latinos are 1.3 times more likely.

Underserved patients are also less likely to receive quality care for their disease. With limited access to treatment, they have a higher rates of hospital readmission and limited renal replacement options. The COVID-19 pandemic exacerbated these inequalities.  

According to the Centers for Medicare & Medicaid Services (CMS):

  • Black/African American people make up 7.5% of all Medicare beneficiaries who are 65 or older, but they represent 28% of Medicare beneficiaries with ESRD.  
  • 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 white ESRD beneficiaries of a similar age.  
  • The 30-day readmission rate for 65-and-older Black/African Americans with ESRD is 19% higher than similarly aged non-Hispanic white Americans with ESRD.

To address some of the country’s stark disparities in ESRD, the Centers for Medicare & Medicaid Innovation (CMMI) has proposed new rules for the mandatory ESRD Treatment Choices (ETC) Model, which launched in January 2021.

If approved, the adjustments would include incentives for clinicians and participating ESRD facilities that address health and socioeconomic disparities. The goal of this proposed rule is to increase access to home dialysis and transplantation for underserved ESRD patients.

The proposed changes, which would take effect January 1, 2022, are notable as being part of the first CMMI program to directly address health equity.  

Using a Two-Tiered Approach to Address Disparities

The proposed changes from CMMI involve a two-tiered approach that would bring benefits to both providers and people with ESRD:  

  1. Add a 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 for participants caring for patients who are dual-eligible, in addition to Medicare patients receiving a low-income subsidy (LIS). Under the proposed rule, providers who can show positive outcomes in the treatment of lower-income patients, either on home dialysis or with a transplant, could earn additional improvement points.
  1. Stratify achievement benchmarks based on patient make-up. Assessment of providers’ performance against achievement benchmarks (set by comparable nephrology practices not in the ETC Model) determines the magnitude of the group’s Performance Payment Adjustment (PPA) on Medicare claims ¾ both for home and in-center dialysis claims. With the proposed adjusted benchmarks, ETC participants who see a high number of dual-eligible or people receiving subsidies can avoid financial penalties. Most importantly, more underrepresented 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.

The public is invited to comment on the proposed changes. Comments are due by August 31, 2021, and can be submitted electronically or mailed to:

Centers for Medicare & Medicaid Services

Department of Health and Human Services,

Attention: CMS-1749-P

P.O. Box 8010

Baltimore, MD 21244-8010

Preparing for the Changes

For years, providers around the country have understood the health disparities among ESRD patients. With these proposed ETC Model changes, CMS is taking initial steps toward reducing those inequities.

With adjusted benchmarking based on patient populations, ETC participants can focus more on providing care and less on possible financial penalties. All of this translates to better outcomes and quality of life for individuals with ESRD.  

Although the proposed ETC Model changes are the first step toward health equity among ESRD patients, they likely will not be the last. ETC participants and providers should expect to see additional health equity incentives in the future and possible penalties for failing to provide more equitable access to care.


Dr. Shika Pappoe is a pioneer, a nephrologist, and the Chief Medical Officer at Strive Health. She has blended medicine, public health, and business administration to give her a perspective that is unlikely to be shared by many others. She completed her undergraduate and medical degrees at Yale University, followed by her internal medicine residency and nephrology fellowship at Brigham and Women’s Hospital. During her fellowship, she returned to the classroom to add a Master of Public health degree from Harvard University. After completing her MPH, she moved to California and joined the Royalty Nephrology Medical Group. While she loved practicing community nephrology, she was eager to return to an academic setting where she could teach, participate in research and work in an innovative care setting. She therefore moved to the nephrology division of the Keck School of Medicine. She was assigned to work at Los Angeles County Hospital, one of the country’s largest safety-net hospitals, where she was able to focus her energies on providing care to underserved communities.

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