Treatment Patterns and Characteristics of Dialysis Facilities Randomly Assigned to the Medicare End-Stage Renal Disease Treatment Choices Model

Wilk, Adam S.; Drewry, Kelsey; Zhang, Rebecca; Pastan, Stephen O.; Thorsness, Rebecca; Trivedi, Amal N.; Patzer, Rachel E.

doi:10.1001/jamanetworkopen.2022.25516

Cited by 5 publications

(3 citation statements)

References 47 publications

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“…16 Despite randomization, there were preintervention imbalances in facility and patient characteristics, as well as use of home dialysis between ETC and non-ETC regions. 17 To account for this, we used a difference-in-differences (DiD) approach to estimate changes in outcomes among patients treated in regions randomly selected for ETC participation, compared with concurrent changes among patients treated in control regions. The model was implemented on January 1, 2021, and is set to run through 2027 (eFigure 1 in Supplement 1 ), during which time CMS will monitor yearly performance for participating facilities and make corresponding payment adjustments to all reimbursements under Medicare’s End-Stage Renal Disease Prospective Payment System.…”

Section: Methodsmentioning

confidence: 99%

“…We conducted a DiD analysis comparing changes in monthly outcome measures between ETC and control regions (first difference) across prepolicy and postpolicy periods (second difference) to account for baseline differences across ETC and control regions. 17 We adjusted the analysis for monthly age, sex, race and ethnicity (derived from the Centers for Medicare & Medicaid Services’ member enrollment file), dual Medicare and Medicaid enrollment (hereafter, dual status), reason for Medicare entitlement, zip code–level poverty and college completion (obtained from the American Community Survey), 22 and monthly county-level COVID-19 mortality rates (obtained from The New York Times ) 23 (eTable 2 in Supplement 1 ). We additionally included month and census-region fixed effects to reflect the cyclical timing of dialysis treatment and the level at which model randomization was stratified.…”

Section: Methodsmentioning

confidence: 99%

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Pay-for-Performance Incentives for Home Dialysis Use and Kidney Transplant

Koukounas,

Kim,

Patzer

et al. 2024

JAMA Health Forum

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ImportanceThe Centers for Medicare &amp; Medicaid Services’ mandatory End-Stage Renal Disease Treatment Choices (ETC) model, launched on January 1, 2021, randomly assigned approximately 30% of US dialysis facilities and managing clinicians to financial incentives to increase the use of home dialysis and kidney transplant.ObjectiveTo assess the ETC’s association with use of home dialysis and kidney transplant during the model’s first 2 years and examine changes in these outcomes by race, ethnicity, and socioeconomic status.Design, Setting, and ParticipantsThis retrospective cross-sectional study 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 data span 4 years (2017-2020) before the implementation of the ETC model on January 1, 2021, and 2 years (2021-2022) following the model’s implementation.ExposureReceiving dialysis treatment in a region randomly assigned to the ETC model.Main Outcomes and MeasuresPrimary outcomes were use of home dialysis and kidney transplant. A difference-in-differences (DiD) approach was used to estimate changes in outcomes among patients treated in regions randomly selected for ETC participation compared with concurrent changes among patients treated in control regions.ResultsThe study population included 724 406 persons with kidney failure (mean [IQR] age, 62.2 [53-72] years; 42.5% female). The proportion of patients receiving home dialysis increased from 12.1% to 14.3% in ETC regions and from 12.9% to 15.1% in control regions, yielding an adjusted DiD estimate of −0.2 percentage points (pp; 95% CI, −0.7 to 0.3 pp). Similar analysis for transplant yielded an adjusted DiD estimate of 0.02 pp (95% CI, −0.01 to 0.04 pp). When further stratified by sociodemographic measures, including age, sex, race and ethnicity, dual Medicare and Medicaid enrollment, and poverty quartile, there was not a statistically significant difference in home dialysis use across joint strata of characteristics and ETC participation.Conclusions and RelevanceIn this cross-sectional study, the first 2 years of the 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.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Pay-for-Performance Incentives for Home Dialysis Use and Kidney Transplant

Koukounas,

Kim,

Patzer

et al. 2024

JAMA Health Forum

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“…First, rates of home dialysis use in the study sample (patients with incident ESKD 66 years or older) are higher than estimates from the US Renal Data System (16.5% vs 9.1% in 2018) and analyses of prevalent patients. 1,6 Differences in inclusion criteria and/or outcome definitions may explain these discrepancies and will be important to reconcile, although they may affect ETC and non-ETC regions similarly. Second, investigating the ETC model's effect across age groups will be important because patients with ESKD are eligible for Medicare coverage regardless of their age, and most prevalent home dialysis patients (62%) are younger than 65 years.…”

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confidence: 99%

Early Findings From Medicare’s End-Stage Renal Disease Treatment Choices Model

2022

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Patients with end-stage kidney disease (ESKD) incur substantial costs for the Medicare program while experiencing high rates of adverse outcomes. 1 Substantial racial, ethnic, and socioeconomic disparities also persist among patients with ESKD. 2 Consequently, improving ESKD care has been a key focus for the US Centers for Medicare & Medicaid Services. A recent major initiative focuses on increasing home dialysis (peritoneal dialysis and home hemodialysis), kidney transplant waitlisting, and living donor transplant rates through Medicare's End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model. 3 In this issue of JAMA Health Forum, Ji and colleagues 4 report what is to our knowledge the first peer-reviewed evaluation of a key outcome in the ETC model. Their study found that financial incentives in the ETC model's first year (2021) had no significant effect on the percentage of patients initiating treatment with home dialysis. Results were consistent across patient characteristics, dialysis facility size, and facility profit status.The ETC model and this evaluative study are important for several reasons. First, the ETC model is one of the largest health care policy experiments in US history and randomizes 30% of hospital referral regions to receive financial incentives. Its randomized design with mandatory participation overcomes issues with selection bias that are typically seen with voluntary models. Second, the policy design tests a meaningful shift in financial incentives through pay-for-performance elements.The ETC model focuses on a parsimonious set of performance measures and uses sizeable payment incentives to motivate changes in practice patterns (up to 8% bonus or −10% penalty in the final year). Third, the ETC model has taken a novel step forward by adding an equity incentive in 2022 to reduce socioeconomic disparities in home dialysis and transplant.Ji and colleagues 4 have provided timely, actionable findings to inform policy implementation of the ETC model. Their evaluation is exemplary in its use of a prespecified analysis plan, power calculations to inform detectable effect sizes, and rigorous sensitivity analyses. Their finding that home dialysis use increased in ETC and non-ETC regions (from 16.5% in 2018 to 20.6% in 2021) is promising because home dialysis is associated with clinical benefits compared with in-center hemodialysis, including improved quality of life and better preservation of residual kidney function. 5 Home dialysis use has been increasing since 2008, so interrupted time series could examine if the increases reported by Ji and colleagues 4 represent a departure from prior trends. 1 This study raises several opportunities for further inquiry. First, rates of home dialysis use in the study sample (patients with incident ESKD 66 years or older) are higher than estimates from the US Renal Data System (16.5% vs 9.1% in 2018) and analyses of prevalent patients. 1,6 Differences in inclusion criteria and/or outcome definitions may explain these discrepancies and will be important...

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