• Kalli G Koukounas, Rebecca Thorsness, Rachel E Patzer, Adam S Wilk, Kelsey M Drewry, Rajnish Mehrotra, Maricruz Rivera-Hernandez, David J Meyers, Daeho Kim, and Amal N Trivedi.
• Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island.
• JAMA. 2024 Jan 9; 331 (2): 124131124-131.

ImportanceThe End-Stage Renal Disease Treatment Choices (ETC) model randomly selected 30% of US dialysis facilities to receive financial incentives based on their use of home dialysis, kidney transplant waitlisting, or transplant receipt. Facilities that disproportionately serve populations with high social risk have a lower use of home dialysis and kidney transplant raising concerns that these sites may fare poorly in the payment model.ObjectiveTo examine first-year ETC model performance scores and financial penalties across dialysis facilities, stratified by their incident patients' social risk.Design, Setting, And ParticipantsA cross-sectional study of 2191 US dialysis facilities that participated in the ETC model from January 1 through December 31, 2021.ExposureComposition of incident patient population, characterized by the proportion of patients who were non-Hispanic Black, Hispanic, living in a highly disadvantaged neighborhood, uninsured, or covered by Medicaid at dialysis initiation. A facility-level composite social risk score assessed whether each facility was in the highest quintile of having 0, 1, or at least 2 of these characteristics.Main Outcomes And MeasuresUse of home dialysis, waitlisting, or transplant; model performance score; and financial penalization.ResultsUsing data from 125 984 incident patients (median age, 65 years [IQR, 54-74]; 41.8% female; 28.6% Black; 11.7% Hispanic), 1071 dialysis facilities (48.9%) had no social risk features, and 491 (22.4%) had 2 or more. In the first year of the ETC model, compared with those with no social risk features, dialysis facilities with 2 or more had lower mean performance scores (3.4 vs 3.6, P = .002) and lower use of home dialysis (14.1% vs 16.0%, P < .001). These facilities had higher receipt of financial penalties (18.5% vs 11.5%, P < .001), more frequently had the highest payment cut of 5% (2.4% vs 0.7%; P = .003), and were less likely to achieve the highest bonus of 4% (0% vs 2.7%; P < .001). Compared with all other facilities, those in the highest quintile of treating uninsured patients or those covered by Medicaid experienced more financial penalties (17.4% vs 12.9%, P = .01) as did those in the highest quintile in the proportion of patients who were Black (18.5% vs 12.6%, P = .001).ConclusionsIn the first year of the Centers for Medicare & Medicaid Services' ETC model, dialysis facilities serving higher proportions of patients with social risk features had lower performance scores and experienced markedly higher receipt of financial penalties.

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