Impact of Randomized Payment Incentives on Disparities in Home Dialysis and Kidney Transplantation

项目总结 肾衰竭是一种危及生命的疾病，对社会上最弱势的人造成不成比例的影响。 美国的社区。大约88%的肾衰竭患者开始血液透析治疗， 中心护理通常需要每周三次治疗，持续3-4个小时。中心内的替代方案 血液透析包括肾移植，这与较低的死亡率和改善的质量有关。 生活和家庭透析，其结果与血液透析相当，但成本更低 并为患者提供更大的灵活性和独立性。但这些治疗方法的使用率很低， 在接受家庭透析和所有导致 移植。2021年1月，医疗保险和医疗补助服务中心(CMS)启动了 分期肾病治疗选择(ETC)模型。这是第一个强制性的模式，是随机的 在美国30%的地区分配透析设施和管理临床医生，以获得财政激励以增加 家庭透析和肾移植的比率。一些观察性研究表明，支付激励 可能会增加家庭透析，但缺乏因果证据，以及支付改革对股权的影响 肾衰竭的治疗方法仍不清楚。更广泛地说，CMS和其他支付者具有基于价值的高级 改善护理质量的支付政策，但这些战略的评估受到 缺乏适当的控制小组，通常是由于全美统一的政策实施。此外， 基于价值的支付可能无意中导致在获得医疗保健方面的差距日益扩大--如果是安全网和 少数群体服务提供商对绩效激励做出回应的资源较少，或者如果绩效 这些措施没有考虑到患者的社会风险。这一提议将检验这样一种假设，即尽管ETC 模式将增加家庭透析和移植的转诊/评估，它还将扩大 这些结果是因为不成比例地为少数族裔和社会弱势患者服务的医疗机构 将获得较低的业绩收益，并且更有可能受到经济处罚。我们的具体目标是： 1.审查ETC模式对家庭透析的使用以及种族/民族和社会经济的影响 家庭透析中的差异，2.确定ETC模式对获取肾脏的差异的影响 移植和3.检查ETC模式对透析设施的影响 患者的社会风险。这项提议是创新的，因为我们利用了前所未有的随机支付改革 评估财政激励对高成本、高需求人群差异的因果影响。我们会 通过对患者地址进行地理编码来获取社区劣势，并最大限度地提高 我们的评估包括了没有传统医疗保险覆盖范围的患者。因此，这项工作将提供 关于健康公平影响的最大随机测试之一的严格的因果证据 美国有史以来进行的支付改革。

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.