After 2 years, ‘no evidence’ of changes in home dialysis, transplant in ESRD demonstration
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Key takeaways:
- The Lewin Group report concluded that financial incentives did not increase home dialysis or transplantation in 2 years.
- There was an increase in training for home dialysis in the first year of the model.
A report evaluating progress in the End-Stage Renal Disease Treatment Choices model concluded that the demonstration showed “no evidence” of improvement in home dialysis and transplant rates after 2 years.
The conclusions of the Lewin Group report, prepared by researchers from the Arbor Research Collaborative for Health and University of Michigan Kidney Epidemiology and Cost Center, mirror what they found in the program’s first year of operations — that the model’s financial incentives provided to dialysis facilities have not lead to expected increases in the rates of home dialysis or kidney transplants or reductions in hospitalizations and Medicare costs.
“Through the first 2 calendar years of the model, there was no evidence of an impact of the [ESRD Treatment Choices] ETC model on the use of home dialysis modalities, transplant waitlisting and living donor transplantation, which are the direct targets of the model’s payment adjustments,” Brighita Negrusa, PhD, and colleagues wrote. “While home dialysis use continued to grow nationally, there was no evidence of faster growth in home dialysis use in the areas selected for the ETC model relative to a comparison group of [hospital referral regions] HRRs not selected for the ETC model.”
Reduce costs
CMS launched the ETC model in January 2021 to “establish incentives to encourage greater use of home dialysis and kidney transplantation, while reducing Medicare expenditures and preserving or enhancing quality of care provided to beneficiaries with ESRD,” according to the report.
The demonstration, which ends in June 2027, includes dialysis facilities selected at random in approximately 30% of HRRs in the United States. The dialysis facilities and clinicians, defined as managing clinicians, receive performance-based payment adjustments based on increasing the number of patients using home dialysis and placed on the waitlist for deceased donor transplant, living donor transplantation and arranged preemptive transplantation.
All dialysis facilities in the ETC areas are required to participate in the demonstration.
In addition to tracking the increased use of home dialysis and improving transplant rates based on financial incentives, CMS was seeking a reduction in hospitalizations and hospital readmissions as part of the demonstration. At the start of the second year of the model, CMS also added health equity provisions to the model intended to reduce disparities in home dialysis and transplantation.
A study recently published in JAMA concluded that dialysis facilities that treated patients facing greater social risk in the ETC model’s first year received lower performance scores and higher financial penalties compared to clinics in the model that did not treat similar patients. In the current report, Negrusa and colleagues wrote CMS’s inclusion of financial incentives in the second year of the model for dialysis clinics to treat patients with higher social risk did not result in a measurable change.
“While the analyses [of patients with higher social risk] examined cumulative impacts of the model during its first 2 years, we also explored whether the observed impacts appeared to shift between the first year of the model and the second year when the health equity provisions went into effect,” the report authors wrote. “However, the overall patterns ... in the relative impacts by patient subgroup were generally similar when examining impacts during each year.”
While placing patients on home dialysis has not changed, the Lewin Group report noted that training for home dialysis increased in the first year of the demonstration. “It will be important to continue to examine the frequency of home dialysis training in future years of the model and assess whether there are subsequent changes in the extent to which patients successfully transition to a home dialysis modality,” according to the report.
Transplants increase
The first year of the ETC model showed an increase in the number of kidney transplants among patients in the demonstration. That increase, however, was not sustained in the second year, according to the report.
“For transplant-related measures, there was no evidence of a change in waitlisting rates in ETC areas relative to comparison areas based on the combined [calendar year] CY 2021 – CY 2022 data,” the authors of the report wrote. “There was evidence of an increase in transplant rates under the ETC model for the combined CY 2021 – CY 2022 period, though this finding reflects relative growth in CY 2021 that was not sustained in CY 2022.”
The impact estimate for the first year of the model led to an estimated 225 additional kidney transplants in ETC areas in 2021, representing a 10% increase vs. pre-ETC transplant rates.
“This observed growth in overall transplants is attributed to growth in deceased donor transplants,” the authors of the report wrote. “Through the first 2 years of the model, there was no impact on living donor transplant rates.”
The report authors concluded that while little change was seen in the first 2 years of the model, “we caution that it is still early to form conclusions about possible longer-term impacts of the model. ETC participants may continue to adapt their practices and learn from ongoing efforts to encourage use of home dialysis and transplantation as successful options for patients.
“This may be important in a context where facilities and managing clinicians identify a wide range of barriers to home dialysis and transplantation that may vary substantially from patient to patient,” they wrote.
Reference:
Negrusa B, et al. End-stage renal disease treatment choices (ETC) model: Second annual evaluation report. https://www.cms.gov/priorities/innovation/data-and-reports/2024/etc-2nd-eval-rpt. Published Jan. 1, 2024. Accessed Jan. 11, 2024.