The nephrology community is in the middle of a randomized trial, aimed at increasing home dialysis use and kidney transplants (1). Experts broadly agree that both modalities are under-used in the United States. The policy experiment—known as the End-Stage Renal Disease Treatment Choices (ETC) model—is being implemented by the Center for Medicare & Medicaid Innovation. ETC randomized 30% of the country to mandatory participation and holds participating providers financially accountable for home dialysis and transplant waitlisting rates.
A recent study in JAMA Health Forum (2), however, questions the model’s efficacy. Using data from all eligible dialysis facilities and managing clinicians under the ETC model, the authors analyzed 18,621 patients initiating dialysis during the first 8 months of the policy. The study found that participating regions (i.e., those subject to ETC’s payment adjustments) did not have statistically different home dialysis rates compared with control regions (only 0.1 percentage points over a base of 20.6%). The study raises a provocative question: Will ETC’s large financial incentives succeed in boosting home dialysis and transplantation rates?
Still, it is probably too soon to dub ETC a policy failure. Given that the financial incentives of the model increase over time and that scaling home dialysis programs can be difficult, future analyses may demonstrate a positive effect on increasing home dialysis use and kidney transplants. However, if ETC is unable to achieve its aims, policymakers must ask, “Why? Were the financial incentives large enough to effect change? Is home dialysis uptake inelastic to incentives because other constraints (e.g., disruptions to the supply chain and patient reticence to home therapies) predominate?
This year, look for studies examining why home dialysis uptake remains sluggish. Moreover, as additional data on ETC are released, look for whether the policy adequately addresses inequities in home dialysis use and transplantation (3). Irrespective of what investigators find, ETC provides a unique opportunity to test whether financial incentives can effectively promote these under-utilized modalities.
References
- 1.↑
Centers for Medicare & Medicaid Services. ESRD Treatment Choices (ETC) model. Published November 22, 2022. Accessed November 22, 2022. https://innovation.cms.gov/innovation-models/esrd-treatment-choices-model
- 2.↑
Ji Y, et al. Financial incentives to facilities and clinicians treating patients with end-stage kidney disease and use of home dialysis: A randomized clinical trial. JAMA Health Forum 2022; 3:e223503. doi: 10.1001/jamahealthforum.2022.3503
- 3.↑
Thorsness R, et al. Association of social risk factors with home dialysis and kidney transplant rates in dialysis facilities. JAMA 2021; 326:2323–2325. doi: 10.1001/jama.2021.18372
