PROJECT SUMMARY
Kidney failure is a life-threatening condition that disproportionately impacts the most socially disadvantaged
communities in the US. Approximately 88% of patients with kidney failure initiate hemodialysis treatment,
where in-center care typically requires thrice-weekly treatments lasting 3-4 hours. Alternatives to in-center
hemodialysis include kidney transplantation, which is associated with lower mortality and improved quality of
life, and home dialysis, which has comparable outcomes to hemodialysis but is associated with lower costs
and offers greater flexibility and independence for patients. But these treatments are substantially underused,
and persistent racial disparities have been documented in receipt of home dialysis and in all steps leading to
transplantation. In January 2021, the Centers for Medicare and Medicaid Services (CMS) initiated the End-
stage Renal Disease Treatment Choices (ETC) Model. This mandatory model – the first of its kind – randomly
assigned dialysis facilities and managing clinicians in 30% of the US to receive financial incentives to increase
rates of home dialysis and kidney transplantation. Some observational studies suggest that payment incentives
may increase home dialysis, but causal evidence is lacking, and the impact of payment reforms on equity in
kidney failure treatments remains unclear. More broadly, CMS and other payers have advanced value-based
payment policies to improve quality of care, but evaluations of these strategies have been hampered by the
absence of appropriate control groups, often due to uniform policy implementation across the U.S. Further,
value-based payments may inadvertently lead to increasing disparities in access to care if safety-net and
minority-serving providers have fewer resources to respond to performance incentives, or if performance
measures fail to account for patients' social risk. This proposal will test the hypothesis that although the ETC
Model will increase home dialysis and referral/evaluation for transplantation, it will also widen disparities in
these outcomes because facilities that disproportionately serve minority and socially disadvantaged patients
will make lower performance gains and will be more likely to receive financial penalties. Our specific aims are:
1. Examine the impact of the ETC Model on the use of home dialysis and racial/ethnic and socioeconomic
disparities in home dialysis, 2. Identify the effects of the ETC Model on disparities in access to kidney
transplantation and 3. Examine consequences of the ETC Model for dialysis facilities according to their
patients' social risk. The proposal is innovative, as we leverage an unprecedented randomized payment reform
to estimate causal effects of financial incentives on disparities for a high-cost, high-need population. We will
derive neighborhood disadvantage by geocoding patient addresses and maximize the comprehensiveness of
our evaluation by including patients who lack traditional Medicare coverage. Thus, this work will provide
rigorous, causal evidence about the health equity implications of one of the largest randomized tests of
payment reform ever conducted in the U.S.