Financial incentives from Medicare’s End-Stage Renal Disease (ESRD) Treatment Choices (ETC) payment program did not increase the home dialysis adoption rate in 2021, the first year of the program, a new study finds.

The mean proportion of patients with any home dialysis in the first 90 days did not differ significantly between ESRD facilities and managing clinicians who did and did not receive financial incentives for home dialysis use: 20.72% vs 20.60%, Yunan Ji, PhD, of Georgetown University in Washington, DC, and colleagues reported in JAMA Health Forum. The percentage of weeks a patient received any home dialysis and the percentage of dialysis sessions performed at home in the first 90 days also did not differ significantly between groups.

In the mandatory ETC trial, investigators randomly assigned 91 hospital referral regions to financial incentives and 211 to no incentives (control). The home dialysis payment adjustment increased the reimbursement rate for home dialysis for the first 3 years, which was 3% in 2021. The performance payment adjustment increases or decreases the reimbursement rate for home and facility dialysis depending on whether the rate of home dialysis and transplant improves.

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Home dialysis costs less than facility-based dialysis and provides comparable if not better clinical outcomes, Dr Ji’s team pointed out. Up to 85% of patients may be suitable candidates. The US Department of Health and Human Services wants 80% of new kidney failure patients to receive home dialysis or a kidney transplant by the year 2025.

According to the investigators, “higher incentives may be necessary to affect behavioral change by dialysis clinicians and facilities.” This analysis only examined the first year of the program, so continued evaluation is warranted.

The trial involved 12,394 managing clinicians and 18,621 patients with ESRD aged 66 years or older (42.1% women) who initiated treatment with dialysis in 2021. Of the patient cohort, 65.7% were White, 17.7% Black, 5.2% Asian, 4.3% Hispanic, and 0.9% Native American. Patient characteristics, dialysis facility size, and facility profit status did not affect the study findings.

In an accompanying editorial, Sri Lekha Tummalapalli, MD, MBA, MAS, of the Division of Healthcare Delivery Science and Innovation at Weill Cornell Medicine in New York, New York, and colleagues argued that more time is needed to properly evaluate the ETC payment model. The shift to home dialysis is “complex and time-consuming,” they explained. To expand home dialysis, nephrologists need to grow in their knowledge of the ETC model, and the health care industry needs to provide greater resources, staffing, and training.

According to Dr Tummalapalli and colleagues, “the ETC model remains a promising, ambitious experiment aiming to improve the care and outcomes for patients with ESKD. Further evaluation and monitoring will be key to assess US progress in advancing kidney health.”

Disclosure: This research was supported by J-PAL North America Health Care Delivery Initiative.


Ji Y, Einav L, Mahoney N, Finkelstein A. Financial incentives to facilities and clinicians treating patients with end-stage kidney disease and use of home dialysis. JAMA Health Forum. Published online October 7, 2022. doi:10.1001/jamahealthforum.2022.3503

Tummalapalli SL, Navathe AS, Ibrahim SA. Early findings from Medicare’s end-stage renal disease treatment choices model. JAMA Health Forum. Published online October 7, 2022. doi:10.1001/jamahealthforum.2022.3500