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Federal Register / Vol. 86, No. 129 / Friday, July 9, 2021 / Proposed Rules
TABLE 19: Difference from Baseline Rounded $M
Year of Model
2021

2022

2023

2024

2025

2026

2027

4.5 Year Total
Net Impact to Medicare Spendin2

-2

-2

0

-1

-1

-7

Overall PPA Net &
HDPA

-2

-2

0

-1

-1

-7

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BILLING CODE 412001C

Table 18 summarizes the estimated impact of the ETC Model when assuming preset benchmark updates where the achievement benchmarks for each year are set using the average of the home dialysis rates for year t-1 and year t-2 for the HRRs randomly selected for participation in the ETC Model. We estimate the Medicare program will save a net total of $53 million from the PPA
and HDPA between January 1, 2021 and June 30, 2027 less $15 million in increased training and education expenditures. Therefore, the net impact to Medicare spending is estimated to be $38 million in savings. In Table 18 and Table 19, negative spending reflects a reduction in Medicare spending, while positive spending reflects an increase.
The results for both tables were generated from an average of 400
simulations under the assumption that benchmarks are rolled forward with a 1.5-year lag.
Table 19 is provided to isolate the total impact of the changes proposed in this proposed rule for years 2023 going forward by calculating the difference from our final estimates in Table 18 less totals from our current baseline estimates that used the same years of data, but without the model changes applied. To clarify, the baseline estimates are not the estimates reported in Table 19 of the Specialty Care Models final rule 85 FR 61354; the final rule used data from CYs 2016 and 2017 and this proposed rule used the most recent data available, from CYs 2018 and 2019.
There was no impact reported in years 2021 and 2022 since the proposed payment adjustments were not effective
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until MY3. In addition, the proposed changes did not apply to the HDPA or the Kidney Disease Patient Education Services Costs and HD Training Costs.
As expected, Table 19 shows that the proposed changes had a very small effect on Medicare savings; only $7
million in savings for the net impact to Medicare spending over the 4.5-year period can be attributed to the changes proposed in this rule.
As was the case in the Specialty Care Models final rule 85 FR 61353, the projections do not include the Part B
premium revenue offset because the payment adjustments under the ETC
Model will not affect beneficiary costsharing. Any potential effects on Medicare Advantage capitation payments were also excluded from the projections. This approach is consistent with how CMS has previously conveyed the primary FFS effects anticipated for an uncertain model without also assessing the potential impact on Medicare Advantage rates.
Returning to Table 18, as anticipated, the expected Medicare program savings were driven by the net effect of the Facility PPA; a reduction in Medicare spending of $74 million over the period from July 1, 2022 through June 30, 2027.
In comparison, the net effect of the Clinician PPA was only $9 million in Medicare savings. This estimate was based on an empirical study of historical home dialysis utilization and transplant waitlist rates for Medicare FFS beneficiaries that CMS virtually attributed to ESRD facilities and to Managing Clinicians based on the plurality of associated spending at the beneficiary level. We analyzed the base
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variation in those facility/practice level measures and simulated the effect of the payment policy assuming providers and suppliers respond by marginally increasing their share of patients utilizing home dialysis. Random variables were used to vary the effectiveness that individual providers and suppliers might show in such progression over time and to simulate the level of year-to-year variation already noted in the base multi-year data that was analyzed. The uncertainty in the projection was illustrated in sections VII.C.2.b.3a and VII.C.2.b.3b of the Specialty Care Models final rule 85 FR 61354, respectively, through alternate scenarios assuming that the benchmarks against which ETC Participants are measured were to not be updated. In those sensitivity analyses, we analyzed a modified version of the model that included a fixed benchmark for the home dialysis and transplant waitlist rates as well as a separate sensitivity analysis that assumed a rolling benchmark for the home dialysis rate and a fixed benchmark for the transplant waitlist rate.
For this proposed rule, we are modeling a preset benchmark growth rate as proposed in this rule but continue to incorporate sensitivity to a range of potential behavioral changes for the home dialysis rate and transplant waitlist rate for ETC facilities and Managing Clinicians assumed to participate in the model. Kidney disease patient education services on treatment modalities and home dialysis HD
training for incident dialysis beneficiaries are relatively small outlays
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09JYP2

EP09JY21.020

0
3 4
2 8
Total PPA Downward -1
Ad.iustment TotalPPA Upward -2
-3
-3
-1
-5
-15
Adjustment Total PPA Net -2
-2
0 -7
-1
-1
TotalHDPA
0 0
Model changes proposed effective for MY 3. Payments adjusted beginning in PPA Period 3, effective July 1, 2023
going forward. No changes to the HDP A. No changes to the Kidney Disease Patient Education Services Costs or the HD
Training Costs. See Table El for additional footnotes.