Discussion
ESRD
ESRD
In the first 18 months of ETC, initiation of home dialysis increased approximately 1% more in ETC markets than in non-ETC markets. Furthermore, although use of home dialysis among incident dialysis patients has been increasing over the past several years, the rate of increase doubled in the first 18 months of implementation of the ETC payment model. This overall acceleration is notable because only 31.2% of patients received care in markets assigned to ETC participation, and only 33.6% of patients were covered by FFS Medicare as the primary payer. These results suggest that the ETC was associated with increases beyond patients covered by the program; analyses stratified by Medicare FFS coverage not only confirm this but further suggest that the results of ETC were greater among patients without FFS coverage, highlighting the difficulty of increasing home dialysis use in the Medicare FFS population in particular.The ETC model appears to have had a relatively immediate association with the behavior of health care professionals providing nephrology and dialysis services, highlighting the power of financial incentives. The ESRD Prospective Payment System and other CMS initiatives previously demonstrated the powerful impact CMS payment models can exert when Medicare is the predominant payer, and home dialysis use had been increasing prior to ETC, likely because of some of these initiatives. However, our results suggest that, even when Medicare FFS is not the largest payer, CMS payment changes may be associated with the behavior of health care professionals providing nephrology services. We speculate that clinicians and facilities that provide dialysis in ETC markets may have responded to ETC assignment by implementing changes in practice for all patients rather than only for those with Medicare FFS coverage in the interest of efficiency or equity. Furthermore, the widespread discussion and publication of US government policy to increase home dialysis may have influenced clinicians and facilities providing nephrology and dialysis services in non-ETC markets to also prioritize expansion of home dialysis use.The apparent initial success of ETC is also remarkable because ETC was implemented with random allocation and mandatory participation to avoid selection bias and ensure generalizeability.A recent study reported that rates of home dialysis among Medicare FFS beneficiaries were not statistically significantly different in ETC and non-ETC markets in the first 9 months of 2021.Although the overall rate of increase in use of home dialysis doubled in the first 18 months of implementation of the ETC payment model compared with before 2021 and the percentage of patients initiating home dialysis increased in ETC markets compared with non-ETC markets, the absolute magnitude of these changes was small. This rate of increase in initiation of home dialysis, if sustained, would lead to rates of initiation of home dialysis comparable to those currently observed in other Western countries (eg, Canada [25.5%]