Medicare’s Financial Incentives Still Falling Flat for Home Dialysis Uptake

Financial incentives used in Medicare’s End-Stage Renal Disease Treatment Choices (ETC) Model didn’t move the needle on home dialysis use and kidney transplantation uptake during its first 2 years.

According to a cross-sectional study, the proportion of kidney failure patients receiving home dialysis living in areas testing the ETC model increased from 12.1% to 14.3%, as compared with 12.9% to 15.1% in control regions, for a nonsignificant difference-in-difference [DiD] of -0.2 percentage points (95% CI -0.7 to 0.3), reported Amal Trivedi, MD, MPH, of Brown University School of Public Health in Providence, Rhode Island, and colleagues.

The null findings held true when the data were further stratified by sociodemographic measures, including age, sex, race and ethnicity, dual Medicare and Medicaid enrollment, and poverty quartile.

A similar pattern followed when it came to kidney transplant uptake. There was an increase from 0.29% to 0.32% in ETC regions versus 0.29% to 0.30% in control regions (DiD estimate 0.02 percentage points, 95% CI -0.01 to 0.04), according to the study in JAMA Health Forum.

The findings were simultaneously presented at the AcademyHealth 2024 annual research meeting in Baltimore.

“Payment penalties and bonuses used in the ETC model, despite being significantly larger than those used in prior kidney care quality incentives, do not appear to be moving the needle significantly on provider behavior,” co-author Kalli Koukounas, MPH, also of Brown University School of Public Health, told MedPage Today.

While this could be due to a number of reasons, Koukounas pointed out that patient-level and socioeconomic barriers are likely contributing.

Lack of stable housing, having to learn and self-administer complex medical regimens, lack of caregiver support, and the financial burden of home modifications and higher utility bills likely contribute to the slow uptake of home dialysis.

“The application of pay-for-performance incentives to dialysis facilities and clinicians does not address these patient-level barriers,” said Koukounas.

As for kidney transplants, she said it could take several years to notice a significant impact from the ETC model, as the process of receiving a transplant is both lengthy and complex.

The model was launched in 2021 by CMS with the intention of increasing the use of home dialysis, kidney transplant, and transplant waitlisting among traditional Medicare beneficiaries. It randomly selected 30% of the nation’s hospital referral regions for mandatory participation, which included all dialysis facilities and managing clinicians in those regions. Participants in these test regions received payment incentives and penalties on the basis of their attributed patients’ use of home dialysis and kidney transplant or waitlisting.

The model is slated to run through 2027. By that year, payment bonuses and penalties will hit 8% and -10%, respectively. In the first 2 years, these ranged from bonuses of 4% to penalties of -5%.

While prior analyses of the ETC model have reported mixed findings, Koukounas pointed out the current study evaluated the first 2 years of implementation across the entire kidney failure population, inclusive of both incident and prevalent patients. That being said, she still wasn’t surprised by the findings given prior reports.

According to previous research from Koukounas’ own team on the first year of the ETC model, she said they found that facilities who served patients with high social risk were disproportionately penalized by the ETC model.

“This is not an uncommon effect among pay-for-performance programs, but is nonetheless cause for concern, particularly due to the fact that kidney failure already has large racial, ethnic, and socioeconomic care disparities,” she said. “This finding coupled with the lack of consistent evidence that the ETC model is improving outcomes may raise concerns about the continued implementation of the model through its scheduled end date.”

The analysis included 724,406 patients with kidney failure. The average age was 62.2 and 42.5% were female.

Compared with control regions, ETC regions had a higher proportion of Black patients (35.4% vs 30.5%) and a lower proportion of white (48.7% vs 50.4%) and Hispanic patients (5.9% vs 8.6%). It also included more people in Southern (47.8% vs 43.8%) and Northern (17.2% vs 14.7%) census regions and fewer in the Midwest (17.8% vs 20.8%) and West (17.2% vs 20.6%) regions. ETC areas also had slightly fewer dual beneficiaries (41.5% vs 42.8%) mostly driven by fewer full dual beneficiaries (32.7% vs 35.1%).

“Going forward, both policymakers and physicians can work together to consider how best to confront the structural barriers that limit the uptake of higher quality care, especially among socioeconomically disadvantaged patient populations,” said Koukounas.

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