← the access Reviewed as of 26 July 2026
THE ACCESS · WHAT GOVERNS A FACILITY?

The Accumulation

How the machinery arrived: five decades of statute, guidance, payment, measurement and models, drawn as load rather than sequence—each instrument arrives at its date and then keeps running, because it is still in force. Almost nothing ever comes off.

TEXT ALTERNATIVE ↓
1980 1980 1990 1990 2000 2000 2010 2010 2020 2020 2030 2030 1978 TIME → READ AS OF JULY 2026 THE LAW 5 INSTRUMENTS · 5 STILL BEARING LOAD 1978 ESRD Networks established — 18 regional bodies PL 99-509 The Network withhold — 50 cents per HD treatment START NOT VERIFIED 15 APR 2008 The Conditions for Coverage — 42 CFR Part 494 1 JAN 2017 ESRD facilities opened to AKI patients STATUTE 2015 → EFFECT 2017 1 JAN 2021 Medicare Advantage opens to ESRD patients THE SURVEY 4 INSTRUMENTS · 4 STILL BEARING LOAD OCT 2008 The V-tags — Interpretive Guidance v1.1 2016 Emergency Preparedness — §494.62 added 2017 Dialysis Facility Report becomes presurvey MAY 2026 ESRD guidance relocated into Appendix H THE MONEY 4 INSTRUMENTS · 4 STILL BEARING LOAD 2008 First federal value-based purchasing authorised 1 JAN 2025 Oral-only phosphate binders enter the bundle 2026 PPS base rate $281.71 per treatment (was $273.82) TDAPA · TPNIES Two temporary side doors in a closed bundle START NOT VERIFIED CY2026 · ZERO APPROVED THE MEASUREMENT 3 INSTRUMENTS · 2 STILL BEARING LOAD 24 JUN 2011 FDA safety communication on ESA dosing 6 NOV 2014 Hemoglobin >12 QIP measure removed START NOT VERIFIED 6 NOV 2014 QIP Up to 2% payment reduction — PY2027 mTPS 57 START NOT VERIFIED TWO CLOCKS, ~2 YEARS APART THE MODELS 4 INSTRUMENTS · 2 STILL BEARING LOAD 2021 ETC Model — mandatory home dialysis/transplant 31 DEC 2025 2022 KCC Model — the KCF option 31 DEC 2025 2022 KCC Model — CKCC: Graduated/Professional/Global 31 DEC 2027 1 JUL 2025 IOTA Model — Increasing Organ Transplant Access 30 JUN 2031 0 5 10 14 THE LOAD INSTRUMENTS IN FORCE, COUNTED FROM THE DATA −2 · 31 DEC 2025 14 IN FORCE · JULY 2026
WIDE DRAWING · SCROLL SIDEWAYS TO READ IT ALL · THE FULL CONTENT IS ALSO IN WORDS BELOW
An instrument—arrives at its date and runs while in force
The band—in force, bearing load to the frame edge
Terminated or removed—the plate’s only red
Start not verified, or scored outside the V-tags
Reviewed as of 26 July 2026 Changelog

The drawing in words

  1. THE LAW. 1978—the ESRD Networks are established: eighteen regional bodies, still here. [1]
  2. Public Law 99-509 §9335—the Network withhold: 50 cents per hemodialysis treatment, PD-adjusted, deducted from facility payment to fund the Networks; codified at SSA §1881(b)(7). The plate places this instrument by its public law number, not by a year: the year is not verified in the dataset. [2]
  3. 15 April 2008—the Conditions for Coverage are issued: 42 CFR Part 494, at 73 FR 20475. The spine everything else hangs from. [3]
  4. Trade Preferences Extension Act of 2015, sec. 808 opened certified ESRD facilities to acute kidney injury patients—effective 1 January 2017. The drawing carries the two-year gap between statute and effect. [4]
  5. 1 January 2021—21st Century Cures Act sec. 17006 opens Medicare Advantage enrollment to ESRD beneficiaries. The payer mix changes permanently. [5]
  6. THE SURVEY. October 2008—ESRD Program Interpretive Guidance v1.1, S&C-09-01: the V-tags, the checkpoints a surveyor cites. [6]
  7. 2016—the Emergency Preparedness rule adds §494.62 to Part 494, but it is scored under SOM Appendix Z as E-tags, not in the V-series: a condition inside the Conditions that the Conditions’ own tag system does not cover. Drawn as an ink rail, in force and outside the V-tags. [3 · 7]
  8. 2017—S&C 17-02: the Dialysis Facility Report becomes presurvey reading. The surveyor arrives having already read your data. [8]
  9. May 2026—QSO-26-09-ESRD relocates the ESRD guidance and survey protocol into State Operations Manual Appendix H, 420 pages. The guidance did not change; where it lives did. The plate draws that as a relocation chain, not a removal—both bands keep running. [9]
  10. THE MONEY. 2008—MIPPA 2008, SSA §1881(h) authorizes the first federal value-based purchasing program in Medicare. [10]
  11. 1 January 2025—oral-only phosphate binders enter the bundle via TDAPA. [11]
  12. 2026—the ESRD PPS base rate is $281.71 per treatment, up from $273.82: one case-mix-adjusted payment covering treatment, equipment, drugs, labs, supplies and capital. [11]
  13. TDAPA and TPNIES—two temporary side doors in a bundle designed to have none. TPNIES pays 65 percent of the MAC-determined price for two years; for CY2026 zero items are approved. The drawing shows that door open and empty. Start years not verified in the dataset. [17 · 18]
  14. THE MEASUREMENT. 24 June 2011—FDA Drug Safety Communication on ESA dosing in chronic kidney disease. The hemoglobin target consensus breaks. [12]
  15. 6 November 2014—the CY2015 final rule removes the hemoglobin-greater-than-12 QIP measure as topped out. Anemia stops being measured directly and starts being measured by its shadows: transfusions, hospitalizations, readmissions. A subtraction, drawn red—five decades of accumulation hold only three of them, and the load line counts two. [13]
  16. The QIP carries up to a 2 percent payment reduction; the PY2027 minimum Total Performance Score is 57. The performance year and the payment year are two different years, roughly two apart. [19 · 20]
  17. THE MODELS. 2021—the ETC (ESRD Treatment Choices) Model begins: a mandatory home-dialysis and transplant model. [14]
  18. 2022—the KCC (Kidney Care Choices) Model begins: a voluntary CKD/ESRD value-based model. Its KCF option ends 31 December 2025. [11 · 15]
  19. The CKCC options—Graduated, Professional, Global—are extended through 31 December 2027, and are still bearing load. [11]
  20. 1 July 2025 to 30 June 2031—the IOTA (Increasing Organ Transplant Access) Model runs. [16]
  21. 31 December 2025—the ETC Model is terminated early in the CY2026 final rule. With the KCF option, it is everything the load line loses in five decades. [11]

BRACKETED NUMBERS TRACE EACH LINE TO THE SOURCE LIST BELOW · EVERY SOURCE IS HELD IN THE REFERENCES LEDGER WITH ITS LOCATOR, ITS LAST-CHECKED DATE, AND HOW IT WAS VERIFIED