The End-Stage Renal Disease (ESRD) Treatment Choices (ETC) model, a significant component of the Advancing American Kidney Health (AAKH) initiative, aimed to increase home dialysis and transplant rates through financial incentives. Despite these efforts, recent studies show that those incentives failed to produce the desired outcomes. Here, Jay Wish, M.D. explains the ETC model’s poor performance, and why its very goals need to be changed.*

What the ETC Model Was Supposed to Do

In 2019, former President Donald Trump signed the Advancing American Kidney Health initiative, aiming to address the challenges of kidney disease, which affects 37 million Americans and consumes one in five Medicare dollars. 

The initiative’s goals were ambitious, Wish says. They included:

• Reducing new cases of kidney failure, and 
• Increasing the rates of home dialysis usage and organ transplants. 
• One specific target was to have 80% of new dialysis patients receiving home dialysis or transplants by 2025.

The Centers for Medicare & Medicaid Services (CMS) launched the ETC model to encourage this shift. This model, mandatory for 30% of dialysis facilities and clinicians randomly selected by region, linked financial incentives to home dialysis and transplant rates. 

Challenges of the ETC Model

Despite the financial incentives, Wish notes, the ETC model has not significantly improved home dialysis or transplant rates. 

In the first two years, the proportion of patients receiving home dialysis increased from:

• 12.1% to 14.3% in ETC regions, and 
• 12.9% to 15.1% in control regions. 

These modest improvements indicate that financial incentives alone are not enough to drive substantial change in patient behaviors or provider practices.

A major reason for the model’s limited success, Wish points out, is its lack of alignment with true patient-centeredness. 

The model primarily focused on cost savings rather than enhancing patient autonomy and informed decision-making. Many patients still prefer the ease and familiarity of in-center hemodialysis (ICHD) over home dialysis, despite the theoretical advantages of the latter. 

The patient-centered approach emphasizes providing comprehensive information and empowering patients to choose the modality that best suits their lifestyle and preferences, a nuance that the ETC model did not fully embrace.

Reassessing AAKH Goals 

The AAKH initiative’s focus on reducing costs through increased use of peritoneal dialysis (PD) and transplants has not necessarily translated into improved patient outcomes or satisfaction. 

• Survival rates for PD and ICHD are comparable, and 
• Quality of life (QoL) advantages appear to be mixed and patient-specific. 

For instance, a review of patient-reported outcomes showed varied results, with some studies favoring PD and others favoring ICHD in different QoL domains.

Barriers to adopting home dialysis also remain significant. Key issues include:

• Inadequate patient education, 
• Lack of infrastructure, and 
• Insufficient clinician support. 

Given these challenges, it’s crucial, Wish says, to reassess the AAKH initiative’s goals and strategies. The primary aim should shift from cost reduction to genuinely improving patient care and outcomes. 

This includes:

• Investing in upstream care for chronic kidney disease (CKD), 
• Enhancing early detection and treatment, and 
• Ensuring that any cost savings are reinvested into the ESRD program to benefit patients directly.

Future Directions

“The ETC is flawed because it is about what the patient chooses, not about how the patient chooses,” Wish explains. 

“What person-centeredness is all about is the process, not the outcome. It is about informed decision-making: Give the patient all the information about the advantages and disadvantages of each choice, then allow the patient (and other stakeholders such as family members who may be needed to implement the choice) to make the decision of what is best for them.”

*Wish, J. B. (2024, July 17). After 2 years, the ESRD Treatment Choices model is – surprise – a bust. Nephrology News and Issues. https://www.healio.com/news/nephrology/20240717/after-2-years-the-esrd-treatment-choices-model-is-surprise-a-bust 

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