Association of Medicare’s ESRD Treatment Choices Model with Timely Access to Kidney Transplantation in the Southeastern United States

BACKGROUND: In 2021, Medicare's End-Stage Renal Disease Treatment Choices (ETC) Model randomly assigned 30% of U.S. dialysis facilities to financial incentives to increase home dialysis, waitlisting, and living-donor kidney transplantation. Early evaluations found no improvements in waitlisting or transplantation, but whether the ETC influenced upstream transplant access steps controlled by dialysis facilities remains unknown. METHODS: Using linked data from the United States Renal Data System, Early Steps to Transplant Access Registry, and Scientific Registry of Transplant Recipients, we assessed the association of ETC implementation with transplant referral within 1 year of dialysis initiation, evaluation initiation within 6 months of referral, waitlisting or living-donor transplantation within 2 years of dialysis initiation, and corresponding time-to-event outcomes. Difference-in-differences analyses compared outcomes at ETC versus control facilities among adult Traditional Medicare beneficiaries initiating dialysis in Georgia, North Carolina, and South Carolina before (2015-2019) and after (2021-2023) ETC implementation. Follow-up extended through December 2024 (referral, evaluation) and June 2025 (waitlisting, transplantation). RESULTS: Among 26,809 individuals in 706 facilities (mean [SD] age, 57 [13]; 43% female; 53% non-Hispanic Black; 46% dual Medicare/Medicaid eligible), ETC implementation was associated with adjusted differential increases in timely referral, evaluation start, and waitlisting or living-donor transplantation of 3.58 (95% CI, -1.30 to 8.45), 8.52 (95% CI, -1.42 to 18.45), and 3.61 (95% CI, -0.26 to 7.48) percentage points, respectively, relative to control facilities. Time-to-event analyses were consistent with primary results and substantial COVID-era delays in transplant referral across both ETC and control regions. CONCLUSIONS: ETC implementation was not associated with definitive evidence of statistically significant improvements in timely transplant referral, evaluation initiation, waitlisting, or living-donor transplantation in the Southeastern U.S. The absence of detectable changes in transplant access processes directly influenced by dialysis facilities suggests that incentive misalignment alone is unlikely to explain the ETC Model's limited impact on transplantation.