CMS’ Financial Incentives Didn’t Move the Dial on Home Dialysis

Financial incentives to encourage home dialysis may be falling flat, according to a first-year analysis of Medicare’s End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model.

Compared with controls, ESRD facilities and managing clinicians practicing within a hospital referral region randomized to receive financial incentives only increased the number of new patients with home dialysis in the first 90 days of treatment by a non-significant 0.12% (P=0.88), reported Yunan Ji, PhD, of Georgetown University in Washington, D.C., and colleagues.

Likewise, no secondary outcomes were significantly different between the groups, including the average percentage of weeks a patient received any home dialysis and number of dialysis sessions at home during the first 90 days.

“This raises questions about the efficacy of the financial incentives in the model and suggests that higher incentives may be necessary to affect behavioral change by dialysis clinicians and facilities,” the group wrote in JAMA Health Forum.

Because prior financial incentives may have dissuaded physicians from encouraging home dialysis, CMS’ ETC Model aimed at bolstering those rates — along with kidney transplant waitlisting and living donor transplant rates — in part through shifting Medicare payments from traditional fee-for-service payments to a value-based payment model.

Ji’s group pointed out that while it’s estimated that up to 85% of patients are likely suitable for home dialysis, only 12.6% of Medicare patients actually received home dialysis in 2019. Because home dialysis is not only cheaper, but also yields the same or better clinical outcomes, CMS announced a goal to have 80% of new ESRD patients receive home dialysis or a transplant by 2025.

This trial looked at outcomes from the first year (2021) of the ETC model, which is slated to stay in place through June 30, 2026. With the ETC model, the home dialysis payment adjustment (HDPA) increases the reimbursement rate for home dialysis for the first 3 years of the program. Additionally, performance payment adjustment (PPA) either increases or lowers the reimbursement rate for home and facility dialysis based on the rate of home dialysis and transplant, both of which are combined into a modality performance score.

“The HDPA increase in reimbursement rate for home dialysis was 3% in 2021, 2% in 2022, and 1% in 2023,” the researchers explained. “The PPA adjustments were potentially much larger and depended on the facility’s modality performance score. They could range from -5% to 4% in the first year and increase over time to -10% to 8% during the last year of the program.”

However, an accompanying editorial led by Sri Lekha Tummalapalli, MD, MBA, MAS, of Weill Cornell Medicine in New York City, suggested that it may just be too early to see a difference, being that the study is only looking at the first year of this model.

Redesigning care to shift dialysis into the home “is complex and time-consuming, and many frontline nephrologists may still be unaware of the ETC model,” they suggested, adding that “growing a home dialysis program requires investments in physical space and changes in staffing, training, and organizational culture.”

On top of this, they also suggested that these ETC incentives may simply not be strong enough to make home dialysis profitable enough to elicit real change. Instead, barriers related to home dialysis must first be addressed in order to truly bolster uptake, they suggested, like improving funding for housing, utility improvements, caregiver support, and staff assistance programs.

The trial included data on 18,621 patients who newly initiated dialysis. These patients were managed within the 302 eligible hospital referral regions included in the trial — 30% of which were randomized to receive these financial incentives.

Both the researchers and the editorialists said they remain eager to see how the subsequent years of the ETC model will play out.