Improving Dialysis and Transplantation: Assessing the Impact of the End-Stage Renal Disease Treatment Choices (ETC) Model

The End-Stage Renal Disease Treatment Choices (ETC) Model, introduced to improve patient outcomes and control healthcare costs, released their second annual evaluation on the impact of the ETC program. This article will explore some key findings – and maybe some missteps – in their area of focus.  

The ETC Model, implemented by the Centers for Medicare & Medicaid Services (CMS), spans approximately 30 percent of Hospital Referral Regions (HRRs) across the United States. These regions, selected through a random process using a U.S. Census Region stratified design, include Maryland, integrated with the ongoing Maryland Total Cost of Care Model. Participation in the ETC Model is mandatory for dialysis facilities and managing clinicians within these selected HRRs.

These entities receive adjustments to certain Medicare fee-for-service (FFS) payments based on their performance under the Model. The performance evaluation criteria encompass various metrics, such as levels of home dialysis utilization, rates of waitlisting for deceased donor transplants, living donor transplantation, and, for specific participants, pre-emptive transplantation, all measured among FFS beneficiaries under their care.

Beginning Jan. 1, 2022, the ETC Model also incorporated health equity provisions aimed at mitigating disparities in access to home dialysis and transplantation. These provisions represent a significant addition to the Model, emphasizing the importance of ensuring equitable access to kidney disease treatment options for all eligible individuals across the covered regions.

Let’s delve into the findings, implications, and potential future impacts of this model.

Home Dialysis Growth and Related Measures

One of the primary goals of the ETC Model has been to encourage the adoption of home dialysis. From 2017-2019 to 2021-2022, home dialysis rates increased by 12 to 15.2 percent in ETC areas and 12.7 to 15.9 percent in the comparison group. Although an 8-percent increase in home dialysis training was observed, the majority of this growth occurred in 2021. Thus, there was no significant difference between the ETC model and the comparison group in the growth of home dialysis utilization.

Waitlisting and Transplantation

The ETC Model did not yield statistically significant differences in waitlisting and living donor transplant rates during its initial two years. While overall transplantation rates saw a 10 percent increase and deceased donor transplant rates rose by 11 percent, this growth was concentrated in 2021 and was not sustained in 2022.

Medicare Spending and Utilization

No significant findings were observed in total Medicare Parts A, B, and D payments per patient, per month, between ETC areas and the comparison group. Likewise, hospitalizations and readmissions showed no significant differences relative to the comparison group.

Patient Behavior

The analysis featured interviews with ETC participants, end-stage renal disease (ESRD) facilities, and managing clinicians, which found no notable shift in behavior beyond existing practices to increase home dialysis in response to the model’s incentives.

Health Equity

Disparities in kidney disease rates and outcomes based on race and ethnicity are publicly known, and historically significant, particularly for Black, Native American, Asian, and Hispanic individuals. However, the evaluation of the ETC Model did not reveal early detectable patterns of different effects of the model on underserved populations.

Conclusion and Future Implications

Through its initial two years, the ETC Model has yielded minimal results. While home dialysis rates experienced a modest increase, the significance of this improvement attributable to the ETC Model remains questionable, compared to conventional nephrology and kidney care practices. The results illuminate several key concepts that appear to be overlooked in the study findings, reflecting external opinions. Much like other healthcare and disease management models, the focus predominantly lies on addressing logistical interventions towards the later stages of kidney care, attempting to resolve complex and longstanding behavioral and disease process issues, with limited success.

The ETC Model doesn’t stand out in its approach, as efforts primarily concentrate on reducing the cost of care by promoting home dialysis over clinic-based treatments and advocating for transplantation, rather than placing emphasis on preventive measures and enhanced management of ESRD from the outset. The study identifies Social Determinants of Health (SDoH) factors, particularly those related to environmental and supportive services necessary for managing home dialysis, as the primary barriers to its adoption, yet this was only recently added, with no structure to address these key areas other than the well-known SDoH assessment tools released in the last couple of years. Additionally, it highlights that facility and clinician practices under the ETC Model were not notably different from the comparison group, suggesting that the metrics were already standards of practice within the ESRD community. This implies that simply augmenting funding within a fee-for-service disease-based model does not inherently incentivize the transformative change necessary for preventing and managing ESRD patients effectively.