End-Stage Renal Disease Payment Model Falls Short of Goals
A study published in *JAMA Health Forum* found that the Centers for Medicare & Medicaid Services’ (CMS) End-Stage Renal Disease Treatment Choices (ETC) model failed to significantly increase home dialysis or kidney transplant rates after four years, despite financial incentives and penalties for providers. The program, launched in 2021 as part of the Advancing American Kidney Health initiative, was terminated early in December 2025 due to limited progress, with negligible differences in outcomes between ETC regions and control areas.
The Centers for Medicare & Medicaid Services’ (CMS) End-Stage Renal Disease Treatment Choices (ETC) model, introduced in 2021, aimed to improve kidney care outcomes by incentivizing home dialysis and transplants through pay-for-performance bonuses and penalties. However, a new study in *JAMA Health Forum* found the program had minimal impact over four years, with home dialysis rates rising only from 12.8% to 16.7% in ETC regions compared to 13.7% to 17.3% in control regions—a negligible 0.1 percentage-point difference. Kidney transplant rates also showed no meaningful improvement, increasing from 3.3 to 4.5 per 1000 patient-months in ETC areas versus 3.4 to 4.4 in controls, a non-significant 0.2 percentage-point gap. The study analyzed Medicare data for 795,232 patients with end-stage kidney disease (ESKD) from January 2017 to September 2024, covering pre- and post-implementation periods. Despite the program’s design to encourage preferred treatments, waitlist rates declined slightly in both groups, with adjusted differences of just 0.6 percentage points. Researchers led by Kalli Koukounas Green, MPH, from Brown University, concluded the ETC model did not meaningfully shift care toward home dialysis or transplants, even after prolonged implementation. Financial penalties under the ETC model became increasingly common, affecting 13.8% of dialysis facilities in 2021 but rising to 25.1% by 2023, with over 40% penalized at least once. Facilities serving higher-risk populations faced disproportionate penalties, though CMS introduced a health equity incentive in 2022 to mitigate disparities. The study noted that penalty rates continued climbing across all groups, suggesting the program’s benchmarks were difficult to meet. Originally set to run through 2027, the ETC model was terminated early in December 2025 due to its limited effectiveness. The findings highlight challenges in using financial incentives to drive behavioral changes in complex healthcare systems, particularly for conditions like ESKD where patient and provider factors play significant roles. Critics argue the model’s rigid thresholds may have hindered progress rather than encouraging better outcomes.
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