Overlap Between Mandatory and Voluntary Value-Based Kidney Care Model Participation and Home Dialysis Use

Importance: End-stage renal disease (ESRD) is a focus of Medicare value-based payment models due to suboptimal quality of care and high health care costs. In 2021 and 2022, 2 models were introduced-the mandatory ESRD Treatment Choices (ETC) model and the voluntary Kidney Care Choices (KCC) model-that included complementary incentives to increase home dialysis use. It is important to understand if participation in either or both models, compared with neither model, is associated with an increase in home dialysis use. Objective: To evaluate whether overlapping participation by nephrologists in the mandatory and voluntary models was associated with higher home dialysis use compared with participation in either model alone or participation in neither model. Design, Setting, and Participants: This cohort study used traditional Medicare claims for a 100% sample of beneficiaries with ESRD receiving dialysis attributed to nephrologists premodel (2016-2020) vs postmodel (2022-2023) implementation. Exposures: Nephrologist participation in the ETC only, KCC only, or both models vs neither model. Main Outcomes and Measures: Percentage of patients by nephrologist model participation group receiving home dialysis. Results: A total of 839 (14.4%) nephrologists (mean [SD] age, 48.5 [9.7] years; 236 [28.1%] female) were in ETC only, 1798 (30.9%) were in KCC only (mean [SD] age, 47.0 [9.5] years; 416 [23.1%] female), 1124 (19.3%) were in both models (mean [SD] age, 46.6 [8.9] years; 284 [25.3%] female), and 2059 (35.4%) were in neither model (mean [SD] age, 49.6 [10.5] years; 556 [27.0%] female). Nephrologist participation in the mandatory ETC model only was not associated with changes in home dialysis use among their attributed patients receiving dialysis compared with neither model. Participation in the voluntary KCC model only was associated with an 8.4% relative increase (95% CI, 3.0%-13.8%; 0.95 percentage points [pp]; 95% CI, 0.34-1.56 pp) in home dialysis use, and participation in both models was associated with an 11.8% relative increase (95% CI, 5.0%-18.6%; 1.29 pp; 95% CI, 0.55-2.03 pp) compared with neither model. Nephrologist participation in both models was associated with increases in home dialysis use that were similar to participation in KCC only (incremental increase, 0.34 pp; 95% CI, -0.37 to 1.05 pp; P = .34). Conclusions and Relevance: This study found that simultaneous participation in mandatory and voluntary kidney care models was common (approximately one-fifth of nephrologists) and associated with increased home dialysis use among patients with ESRD compared with participation in the mandatory payment model only, but not when compared with participation in the voluntary payment model alone. Despite complementary incentives, the results did not suggest a synergistic effect of overlapping participation in 2 value-based kidney care models.