INDIANAPOLIS – A research letter published in the New England Journal of Medicine calls for careful consideration of the design and consequences of health disparity incentives in future value-based payment models.
The research letter delves into the End-Stage Renal Disease Treatment Choices Model. The Centers for Medicare and Medicaid Services (CMS) developed this pay-for performance program to encourage greater use of home dialysis and kidney transplants for Medicare beneficiaries with end-stage kidney disease, while preserving or enhancing quality of care and reducing Medicare expenditures.
Patients receiving home dialysis and kidney transplants are generally considered to have better quality of life compared to patients receiving conventional in-center dialysis. Individuals of any age with end-stage kidney disease are typically eligible for Medicare coverage for this condition.
The innovative payment model is one of the largest randomized evaluations of pay-for-performance ever conducted in the United States. It randomly assigned dialysis facilities and nephrologists in 30 percent of hospital referral regions in the country to receive financial incentives based on how often their patients received home dialysis, received a kidney transplant or were placed on a kidney transplant waitlist.
In 2021, the payment model’s inaugural year, dialysis facilities that disproportionately served patients with social risk factors experienced substantially higher rates of financial penalties. Subsequently, Medicare implemented an incentive to benefit those facilities treating disproportionately many individuals dually eligible for Medicare and Medicaid or receiving Medicare’s low-income subsidy to reduce disparities in access to home dialysis and kidney transplants.
The research letter notes that the introduction of this incentive did not narrow disparities in home dialysis, transplant and waitlisting, possibly due to social risk factors which were not considered in the incentive calculation.
However, the added incentive did reduce financial penalties among facilities that disproportionately serve patients who were Black, Hispanic, uninsured or Medicaid-covered, or living in the most socially disadvantaged neighborhoods.
“Major causes of end-stage kidney failure include diabetes, obesity and hypertension, all conditions which significantly impact individuals in disadvantaged communities throughout the course of their lives,” notes research letter co-author Rachel Patzer, PhD, MPH, president and chief executive officer of Regenstrief Institute and the Leonard Betley Professor of Surgery at the IU School of Medicine. “It’s important that payment systems recognize the facilities that disproportionately serve patients in these communities, so that they are not unfairly penalized and can continue to help meet their patients’ needs.”
In addition to Dr. Patzer, Regenstrief Institute and the IU School of Medicine research scientists Adam Wilk, PhD, and Kelsey Drewry, PhD, M.A., are co-authors. Both Dr. Wilk and Dr. Drewry are health economists and health services researchers.
The new paper is published in the New England Journal of Medicine.
This work was supported by grants from the National Institutes of Health’s (NIH’s) National Institute on Minority Health and Health Disparities (R01 MD017080): Principal Investigators (PIs): Amal N. Trivedi, M.D., MPH, and Rachel E. Patzer, PhD, MPH; and NIH’s National Institute of Diabetes and Digestive and Kidney Diseases (R01DK113298) PI: Dr. Trivedi.
All authors and their affiliations, as listed in the online publication
Kalli G. Koukounas, MPH1, Meehir N. Dixit, BA1, Rebecca Thorsness, PhD2, Rachel E. Patzer, PhD, MPH3, Adam S. Wilk, PhD3, Kelsey M. Drewry, PhD3, Rajnish Mehrotra, MD MS4, Maricruz Rivera-Hernandez, PhD1, David J. Meyers, PhD, MPH1, Daeho Kim, PhD1, Ankur D. Shah, MD5, Christopher H. Schmid, PhD6, Amal N. Trivedi, MD, MPH1.
1Brown University School of Public Health, Providence RI
2VA Boston Healthcare System, Boston MA
3Regenstrief Institute, Indianapolis IN
4University of Washington School of Medicine, Seattle, WA
5Warren Alpert Medical School of Brown University, Providence RI
6Brown University School of Public Health, Providence, RI
2024 study evaluating first year ESRD treatment choices model
A 2024 study evaluating the first year of the model, “Social Risk and Dialysis Facility Performance in the First Year of the ESRD Treatment Choices Model” was published in the Journal of the American Medical Association (JAMA). This study, of which Drs. Patzer, Wilk and Drewry were also co-authors, found that facilities that disproportionately serve populations with high social risk have lower use of home dialysis and transplant waitlisting and fewer kidney transplants.
Rachel Patzer, PhD, MPH
In addition to her roles as president and Chief Executive Officer and research scientist with Regenstrief Institute, Rachel Patzer, PhD, MPH, serves as the Leonard Betley Professor of Surgery at Indiana University School of Medicine and an adjunct professor at IU Richard M. Fairbanks School of Public Health. Dr. Patzer is an epidemiologist and health services researcher with a strong focus on healthcare access, quality of healthcare delivery and outcomes. Her research centers on such key areas as disparities, social determinants of health, community-based participatory research, predictive analytics, healthcare quality and health policy evaluations. She has been instrumental in reshaping the national organ transplantation paradigm, advocating for a population health approach to inform quality measures, policies and fair solutions.
