Ensuring the Equitable Advancement of American Kidney Health—the Need to Account for Socioeconomic Disparities in the ESRD Treatment Choices Model

The finalized ESRD Treatment Choices (ETC) payment model was announced by the Centers for Medicare & Medicaid Services (CMS) on September 18, 2020.1 Recognizing the underutilization of home dialysis and kidney transplantation, CMS introduced the ETC model as part of the Advancing American Kidney Health (AAKH) initiative—a broadsweeping initiative to transform care for patients with kidney failure.1 In keeping with two central AAKH goals, the ETC model will adjust payments to incentivize home dialysis and transplantation. Given the large-scale, mandatory nature of the model, it is critical that CMS continues to refine the model on the basis of public feedback from participants, patients, and organizations. Substantial concern remains that the model does not incorporate risk adjustment—particularly for social determinants of health (SDOHs), such as housing instability, socioeconomic status, and access to care.2 Although strategies to address health care disparities that leverage the broader AAKH initiative have been discussed previously, this perspective serves to summarize key aspects of the ETC model (a specific payment model within AAKH), spotlight concerns regarding the effect of the model on health care disparities, and suggest strategies to promote health equity. THE ETC MODEL—A HIGH-LEVEL OVERVIEW