End-Stage Renal Disease Treatment Choices Model and Use of Home Dialysis and Kidney Transplant.

Importance: To increase the use of home dialysis and kidney transplant, the Centers for Medicare & Medicaid Services launched the End-Stage Renal Disease Treatment Choices (ETC) model, a mandatory, randomized pay-for-performance program applied to 30% of US hospital referral regions. Its impact after 4 years of implementation is uncertain. Objective: To assess the ETC model's impact on home dialysis, kidney transplant, and transplant waitlist, as well as measure the rate of financial penalties. Design, Setting, and Participants: This retrospective cross-sectional study used traditional Medicare claims and enrollment data for beneficiaries with kidney failure linked to concurrent transplant data from the United Network for Organ Sharing from January 1, 2017 (4 years before model implementation), to September 30, 2024 (3.75 years postimplementation). Exposures: Receiving dialysis treatment in a region randomly assigned to the ETC model. Main Outcomes and Measures: Primary outcomes were rates of home dialysis, kidney transplant, and transplant waitlist, as well as facility-level financial penalization. Facility-level financial penalties were assessed using Centers for Medicare & Medicaid Services-published performance data. Results: The study population included 795 232 persons with kidney failure (mean [SD] age, 61.8 [14.4] years; 41.5% female), reflecting 20 729 696 person-months from January 1, 2017, to September 30, 2024. The rate of home dialysis increased from 12.8% to 16.7% of attributed patient-months in ETC regions (change of 3.9 percentage points [pp]) and from 13.7% to 17.3% in control regions (change of 3.7 pp), yielding an adjusted differences-in-differences of -0.1 pp (95% CI, -0.6 to 0.5 pp). The number of kidney transplants per 1000 patient-months increased from 3.3 to 4.5 in ETC regions (change of 1.2) and from 3.4 to 4.4 in control regions (change of 1.0), resulting in a differences-in-differences of 0.2 pp (95% CI, -0.1 to 0.4 pp). The percentage of patients per month on the transplant waitlist decreased from 16.1% to 15.5% in ETC regions (change of -0.5 pp) and from 17.7% to 16.7% in control regions (change of -1.0 pp). The adjusted differences-in-differences for transplant waitlist was 0.6 pp (95% CI, -0.3 to 1.6 pp). The proportion of ETC facilities receiving financial penalties increased from 13.8% in 2021 to 25.1% in 2023. Subgroup analyses showed no meaningful differential effects of the model. Conclusions and Relevance: This cross-sectional study shows that after nearly 4 years, the ETC model was not associated with meaningful increases in home dialysis, kidney transplant, or transplant waitlist, while the proportion of facilities receiving financial penalties increased. Future value-based payment models may need to move beyond narrowly targeted financial incentives to address the broader structural and patient-level barriers that influence access to complex specialty care.