Recently, JAMA Health Forum published an investigation, “Pay-for-Performance Incentives for Home Dialysis Use and Kidney Transplant,” focused on the Centers for Medicare and Medicaid Services (CMS) End-Stage Renal Disease Treatment Choices (ETC) Model. According to the study, there were no statistically significant differences in the use of home dialysis or kidney transplant between those treated in regions randomly assigned to the ETC model and those treated in the control regions.
The ETC model launched on January 1, 2021, and randomly assigned roughly 30% of United States dialysis facilities and managing clinicians to financial incentives, to increase the use of home dialysis and kidney transplant. Participating facilities and clinicians received payment incentives and penalties on the basis of their attributed patients’ use of home dialysis and kidney transplant or wait-listing.
The Study
In performing the study, authors used claims and enrollment data for traditional Medicare beneficiaries with kidney failure from 2017 to 2022, linked to same-period transplant data from the United Network for Organ Sharing. The study considered data from four years prior to the ETC model implementation (2017 to 2020) and two years after the implementation (2021 to 2022).
The total study population included more than 724,000 patients with kidney failure. The proportion of patients who received home dialysis increased from 12.1% to 14.3% in ETC regions and from 12.9% to 15.1% in control regions. Study authors note that while CMS measures kidney transplant and transplant wait-listing as part of its ETC model evaluation, data limitations prevented the authors from incorporating transplant wait-listing in this study. Additionally, when further examined in the context of age, sex, race and ethnicity, dual Medicare and Medicaid enrollment, and poverty quartile, there was no statistically significant difference in home dialysis use.
Study authors note that with the concurrent launch of the 21st Century Cares Act on January 1, 2021, a significant portion of patients with kidney failure left traditional Medicare for Medicare Advantage at the same time the ETC model was launched, making them ineligible for participation in the model.
The authors of the study concluded that in the first two years of the ETC model, there was no increased use of home dialysis or kidney transplant, nor were there changes in racial, ethnic, or socioeconomic disparities in the outcomes. However, the ETC’s limited influence may be attributed to several factors, including the financial incentive created in the 2009 Prospective Payment System to increase home dialysis use to all national dialysis facilities. Additionally, it bears mentioning that successful use of home dialysis requires stable housing as well as the ability to learn and self-administer complex medical regimens; pay-for-play performance incentives to dialysis facilities do not address these possible patient barriers. Further, the process of kidney transplant is lengthy and complex, possibly resulting in a time delay before we are able to see any impact of the ETC model on access to transplants.
The model is set to run through 2027, at which time outcomes will be measured of participating facilities against their own historic performance and the performance of non-participating peers.