Brown University Study Finds No Increase in Home Dialysis or Kidney Transplantation with Government’s Pay-For-Performance Program


Brown University Study Finds No Increase in Home Dialysis or Kidney Transplantation with Government’s Pay-For-Performance Program Interview with:

Amal Trivedi, MD, MPHProfessor of Health Services, Policy & Practice Brown University School of Public HealthAmal Trivedi, MD, MPHProfessor of Health Services, Policy & Practice Brown University School of Public Health

Prof. Trivedi

Amal Trivedi, MD, MPH
Professor of Health Services, Policy & Practice
Brown University School of Public Health What is the background for this study?

Response: On January 1st, 2021, the Centers for Medicare & Medicaid Services (CMS) launched the mandatory End-Stage Renal Disease Treatment Choices (ETC) Model, which randomly assigned approximately 30% of U.S. dialysis facilities and managing clinicians to financial incentives to increase the use of home dialysis and kidney transplantation. The program is set to run through 2027, with financial incentives and penalties increasing as the model progresses.

Our study sought to assess the ETC’s effect on these outcomes of interest in the first two years, as well as to examine outcome changes by race, ethnicity and socioeconomic status. What are the main findings?

Response:  Our findings showed that the first two years of CMS’ ETC model were not associated with increased use of home dialysis or kidney transplant, nor changes in racial, ethnic and socioeconomic disparities in these outcomes. Over the study period, the proportion of patients receiving home dialysis increased from a 12.1% pre-policy average to a 14.3% post-policy average in ETC regions, and 12.9% to 15.1% in control regions, yielding an adjusted difference-in-differences estimate of -0.20 percentage points (95% CI -0.73, 0.33). Similar analysis for transplantation yielded an adjusted difference-in-differences of 0.02 percentage points. Therefore, despite temporal increases in utilization of these services nationally, the ETC model did not differentially increase service use among patients treated by model participants relative to those treated by dialysis facilities in control regions.  What are some of the factors limiting acceptance of home dialysis or transplant enrollment?

Response: There can be patient-level barriers to the uptake of home dialysis, which requires stable housing, the ability to learn and self-administer complex medical regimens, significant family and caregiver support and the financial resources for potential home modifications and higher utility bills. The application of pay-for-performance incentives to dialysis facilities and clinicians does not address these patient-level barriers. Further, if a dialysis facility did not previously have a home dialysis program in place, or have significant experience implementing the service, it could take time to develop the care patterns and resources needed to move significant numbers of patients to the service.

The process of kidney transplant is lengthy, complex and requires several steps from referral to evaluation, waitlisting and ultimately transplantation. As such, it may take several years to observe any impact from the ETC model on transplant access. However, research has demonstrated that racial differences exist at most steps of the transplant process, though the introduction of the 2014 Kidney Allocation System policy did produce some downstream progress.

Going forward, CMS could consider providing additional resources to facilities, particularly those that treat patients with higher social risk, to help overcome structural barriers that prevent the uptake of home dialysis or kidney transplant. What should readers take away from your report?

Response: This study has added to the literature that demonstrates a lack of consistent evidence that the ETC model is improving home dialysis and kidney transplant outcomes, particularly among the prevalent population. The model is currently set to run through 2027, during which time the payment bonuses and penalties will ultimately escalate to +8% and -10% respectively. A prior study by our team demonstrated the ETC’s models disproportionate penalization of facilities serving patients with high social risk in its first year. Together, these findings raise concerns about the continued implementation of the model as is through its scheduled end date. What recommendations do you have for future research as a results of this study?

Response: Researchers should continue to monitor the ETC’s impact on patients and safety-net dialysis facilities, to ensure escalating penalties do not contribute to widening disparities in kidney failure care. Further, transplant outcomes should be particularly of focus as the model progresses, given the longer time horizon to impact.

No disclosures to add.


Koukounas KGKim DPatzer RE, et al. Pay-for-Performance Incentives for Home Dialysis Use and Kidney Transplant. JAMA Health Forum. 2024;5(6.9):e242055. doi:10.1001/jamahealthforum.2024.2055

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Last Updated on July 1, 2024 by Marie Benz MD FAAD



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