Value-Based Kidney Care: Lessons from ETC & Future Models | Healio

The landscape of kidney care policy is undergoing a period of intense scrutiny and revision, spurred by lessons learned from recent value-based care models. A key takeaway from the End-Stage Renal Disease Treatment Choices (ETC) model, and its successor the Kidney Care Choices (KCC) model, is that financial incentives alone are insufficient to drive meaningful improvements in home dialysis and kidney transplantation rates. These findings, presented at the Annual Dialysis Conference, underscore the necessitate for a more holistic approach that addresses systemic barriers to care and prioritizes patient education and support.

Lessons from Recent Kidney Care Models

The ETC model, launched in January 2021 as part of the Advancing American Kidney Health initiative, aimed to increase the proportion of patients receiving dialysis at home and undergoing kidney transplantation. Participating dialysis facilities and nephrology practices faced potential financial adjustments – up to an 8% bonus or a 10% penalty – based on their performance. Though, initial analyses revealed limited success. While home dialysis rates increased modestly, the change wasn’t statistically significant compared to facilities not participating in the model. Studies showed no significant increases in kidney transplant wait-listing or actual transplant rates during the first three years. The model ultimately ended in 2025, costing Medicare nearly $100 million without achieving its desired outcomes.

In contrast, the voluntary Kidney Care Choices (KCC) model, which focused on incentivizing optimal dialysis starts and kidney transplant payment bonuses, demonstrated some positive results. It was associated with increased preemptive kidney transplants, more living donor transplants, and greater leverage of home dialysis modalities. However, even the KCC model resulted in a net loss of $300 million for Medicare, highlighting the financial challenges of incentivizing quality improvements. CMS is currently revising the KCC model for continuation through 2027.

Beyond Financial Incentives: Addressing Systemic Barriers

Suzanne Watnick, MD, FASN, professor of medicine at University of Washington, Seattle, and American Society of Nephrology health policy scholar in residence, emphasized that the failures of the ETC model weren’t simply about the incentives themselves, but about the underlying barriers patients face. These barriers include a lack of education about treatment options, difficulties with transportation, limited access to mental health resources, and communication breakdowns during the kidney transplantation process. Addressing these issues requires a multi-faceted approach that goes beyond simply offering financial rewards.

The need for improved patient education is particularly crucial. Many individuals with kidney disease are unaware of the benefits of home dialysis or the possibility of transplantation. Providing clear, accessible information about these options, and addressing patient concerns and fears, is essential for increasing uptake. Similarly, addressing transportation challenges and ensuring access to mental health support can remove significant obstacles to care.

Novel Models and Legislative Efforts

Despite the challenges, several new initiatives are underway that offer potential for improving kidney care. The Increasing Organ Transplant Access (IOTA) model, launched in July 2024, mandates that 50% of U.S. Transplant centers increase transplantation rates, lower kidney discard rates, and improve long-term transplant survival. This model places a strong emphasis on performance metrics, with higher transplant rates contributing to 60% of the scoring used to determine payment levels. Details on the IOTA model are available on the CMS website.

the Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) model, announced in December 2025, aims to integrate new technologies into patient care. This model will focus on four tracks, including cardio-kidney-metabolic (CKM) disease and early CKM, potentially allowing patients direct access to technology without requiring a physician referral. More information on the ACCESS model can be found on the CMS website.

Legislative efforts are also underway to support kidney transplantation and living donation. The Honor Our Living Donors (HOLD) Act, recently passed in appropriation bills, aims to reduce financial barriers for living kidney donors by considering their income instead of the recipient’s income when determining eligibility for government funds. It also provides support for expenses such as childcare, transportation, and lost wages. The Kidney Foundation provides updates on the HOLD Act and other legislative initiatives.

What Comes Next: A Call to Action for Nephrologists

Watnick stressed the importance of nephrologists and kidney care professionals becoming actively involved in shaping kidney care policy. She encouraged individual engagement with local and state representatives, advocating for policies that support patients and improve access to care. Collaboration with nephrology societies can amplify these efforts, allowing for the drafting of legislation, advocacy for regulatory changes, and the launch of grassroots campaigns.

“People feel that they can’t do a lot individually, but there is really so much we can do,” Watnick said. “You can have separate meetings with your local state representative and senator at local offices. If we do that and get our members of Congress to sign on to bills, those lists get longer on both sides of the aisle. You can get a bill passed that way.”

The future of kidney care hinges on a collaborative effort to address systemic barriers, embrace innovative technologies, and advocate for policies that prioritize patient well-being. The lessons learned from the ETC and KCC models serve as a crucial reminder that financial incentives alone are not enough – a comprehensive, patient-centered approach is essential for improving outcomes and ensuring equitable access to high-quality kidney care.

Suzanne Watnick, MD, FASN, can be reached at [email protected].