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The Advancing American Kidney Health (AAKH) initiative has four major goals: early detection of CKD, preventing CKD progression, promoting kidney transplants, and increasing home dialysis (1). The AAKH has undoubtedly increased excitement among the nephrology community, specifically as it relates to home dialysis. Because the initiative has the potential to dramatically change the face of nephrology care in the United States, it is critical that all steps be taken to ensure its success. Poorly executed efforts to rapidly increase home dialysis without promoting and funding a robust infrastructure may result in suboptimal outcomes, thus having an unintended, prolonged negative effect on home dialysis. Herein, we evaluate the feasibility of the proposed payment model to support the growth of home dialysis and its associated infrastructure, potential unintended consequences of rapid home dialysis growth, the importance of maintaining patient choice in modality selection, and propose adjunctive programs to ensure a safe and sustainable growth in home dialysis.The AAKH initiative proposes a mandatory payment model, the End Stage Kidney Disease Treatment Choices Model (ETC), which will randomize new ESKD starts during 2020–2022 into one of two treatment arms (Figure 1). Centers allocated to the ETC arm will receive a financial incentive or penalty on the basis of performance metrics, in particular the fraction of total dialysis beneficiary years that are on home dialysis. Specifically, there will be 3%, 2%, and 1% Home Dialysis Payment Adjustment in calendar years 2020, 2021, and 2022, respectively. Furthermore, there will be a Performance Payment Adjustment with a possible upward adjustment of 5% and downward adjustment of 8% to the facility and a possible upward adjustment of 5% and downward adjustment of 6% to the provider in periods 1 and 2, with subsequent adjustments in future periods. Furthermore, those in the ETC model would receive an incentive …

ESKD Treatment Choices Model: Responsible Home Dialysis Growth Requires Systems Changes