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

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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.