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Abstract: SA-PO658

First-Year Impact of the ESRD Treatment Choices (ETC) Model

Session Information

  • Home Dialysis - II
    November 04, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
    Abstract Time: 10:00 AM - 12:00 PM

Category: Dialysis

  • 802 Dialysis: Home Dialysis and Peritoneal Dialysis


  • Negrusa, Brighita Mona, Lewin Group Inc, Falls Church, Virginia, United States
  • Ullman, Darin F., Lewin Group Inc, Falls Church, Virginia, United States
  • Turenne, Marc, Arbor Research Collaborative for Health, Ann Arbor, Michigan, United States
  • Mukhopadhyay, Purna, Arbor Research Collaborative for Health, Ann Arbor, Michigan, United States
  • Young, Eric W., Arbor Research Collaborative for Health, Ann Arbor, Michigan, United States

The ETC Model is intended to boost use of home dialysis and kidney transplantation among Medicare fee-for-service beneficiaries with ESRD, while reducing Medicare expenditures and preserving quality of care through performance-based Medicare payment adjustments to ETC participants. We examined impacts in the first year of the ETC Model (2021).


CMS randomly selected 91 Hospital Referral Regions (HRRs) and four HRRs from Maryland for the ETC Model, with mandatory participation from ESRD facilities and Managing Clinicians. We used difference-in-differences (DiD) regression models to compare changes in outcomes in the 95 ETC HRRs with those in 211 comparison HRRs between 2017-2019 and 2021. We used data from Medicare claims, the ESRD Quality Reporting System, the Scientific Registry of Transplant Recipients, and the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems survey to evaluate impacts on dialysis modality, transplant, utilization, Medicare spending, and patient experience of care.


ETC HRRs constituted 31% of HRRs nationwide and included 2,519 ESRD facilities, 4,749 Managing Clinicians and 99,699 beneficiaries in 2021. Home dialysis increased similarly in ETC (11.8 to 14.7% of patient months) and comparison (12.8 to 15.8%) areas, yielding a non-significant (NS) DiD estimate of -0.11%. Home dialysis training increased 9% more in ETC vs. comparison areas (p<0.05). Transplant waitlisting showed a slower decline in ETC (19.5 to 19.0%) vs. comparison (21.1 to 19.8%) areas (DiD=0.83%, (p<0.1). Living donor kidney transplant rates fell similarly in ETC and comparison areas (DiD=0.005, NS). Although not directly incentivized by ETC, deceased donor transplants increased more in ETC (3.2 to 4.5 transplants per 1,000 patient months) vs. comparison (3.3 to 4.1) areas (DiD=0.37, p<0.1). There was no early impact on hospital utilization, overall Medicare spending and in-center hemodialysis patient experience of care.


Through the first year of the ETC Model, there was evidence of modest gains in home dialysis training, transplant waitlisting and deceased donor transplants, but no impact on home dialysis use or living donor transplants. These are early findings. Future analyses will consider the impact of provider infrastructure development and increased payment adjustments.


  • Other U.S. Government Support