RDN Staffing Dialysis Clinics Ratio – Payment and Coverage Priority

The Academy, in partnership with the Renal DPG, submitted comments to CMS on November 6 that a RDN staffing ratio for dialysis clinics be required. The Academy included this recommendation in its comments to the Calendar Year 2027 End Stage Renal Disease (ESRD) Prospective Payment System (PPS) proposed rule.

The National Kidney Foundation (NKF) also supports this recommendation to CMS. The final rule was released on October 30, 2026 – and CMS wrote that they will consider the recommendation "to potentially inform future rulemaking." The staffing ratio was not in the proposed rule, so this is a win for the profession.

The Proposal

The Academy and the Renal DPG recommend that a 1:<=100 staffing ratio for RDNs in dialysis clinics be implemented by CMS. The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) long maintained that 1:<=100 RDN to patient staffing ratio in dialysis clinics is the baseline requirement to effectively deliver medical nutrition therapy (MNT). The staffing ratio has been a gold standard for 26 years, however staffing ratios can vary by state.

Medicare's outpatient MNT benefit explicitly excludes beneficiaries on dialysis and coverage is presumed to already be bundled into the facility's ESRD PPS payment. The dialysis facility RDN is the only nutrition care access point available to these patients. Without a mandated staffing ratio, CMS has no mechanism to ensure that access actually exists in practice, regardless of how the bundle is funded.

The Academy has compiled evidence in support of the staffing ratio and the Renal DPG is collaborating with the University of Colorado-Anschutz on an ongoing study on this issue. The Academy will continue, in partnership with NKF, to advocate for the staffing ratio with CMS.