Health Insurance and the Use of Peritoneal Dialysis in the United States

BACKGROUND

Many patients in the United States have limited or no health insurance at the time they develop end-stage renal disease (ESRD). We examined whether health insurance limitations affected the likelihood of peritoneal dialysis (PD) use.

STUDY DESIGN

Retrospective cohort analysis of patients from the US Renal Data System initiating dialysis therapy in 2006 through 2012.

SETTING & PARTICIPANTS

We identified socioeconomically similar groups of patients to examine the association between health insurance and PD use. Patients aged 60 to 64 years with "limited insurance" (defined as having Medicaid or no insurance) at ESRD onset were compared with patients aged 66 to 70 years who were dually eligible for Medicare and Medicaid at ESRD onset.

PREDICTOR

Type of insurance coverage at ESRD onset.

OUTCOMES

The likelihoods of receiving PD before dialysis month 4, when all patients qualified for Medicare due to ESRD, and of switching to PD therapy following receipt of Medicare.

RESULTS

After adjusting for observable patient and geographic differences, patients with limited insurance had an absolute 2.4% (95% CI, 1.1%-3.7%) lower probability of PD use by dialysis month 4 compared with patients with Medicare at ESRD onset. The association between insurance and PD use reversed when patients became Medicare eligible; patients with limited insurance had a 3-fold higher rate of switching to PD therapy between months 4 and 12 of dialysis (HR, 2.9; 95% CI, 1.8-4.6) compared with patients with Medicare at ESRD onset.

LIMITATIONS

Because this study was observational, there is a potential for bias from unmeasured patient-level factors.

CONCLUSIONS

Despite Medicare's policy of covering patients in the month that they initiate PD therapy, insurance limitations remain a barrier to PD use for many patients. Educating providers about Medicare reimbursement policy and expanding access to pre-ESRD education and training may help overcome these barriers.

A payer-provider partnership for integrated care of patients receiving dialysis

OBJECTIVES

Patients with end-stage renal disease (ESRD) are clinically complex, requiring intensive and costly care. Coordinated care may improve outcomes and reduce costs. The objective of this study was to determine the impact of a payer-provider care partnership on key clinical and economic outcomes in enrolled patients with ESRD.

STUDY DESIGN

Retrospective observational study.

METHODS

Data on patient demographics and clinical outcomes were abstracted from the electronic health records of the dialysis provider. Data on healthcare costs were collected from payer claims. Data were collected for a baseline period prior to initiation of the partnership (July 2011-June 2012) and for two 12-month periods following initiation (April 2013-March 2014 and April 2014-March 2015).

RESULTS

Among both Medicare Advantage and commercial insurance program members, the rate of central venous catheter use for vascular access was lower following initiation of the partnership compared with the baseline period. Likewise, hospital admission rates, emergency department visit rates, and readmission rates were lower following partnership initiation. Rates of influenza and pneumococcal vaccination were higher than 95% throughout all 3 time periods. Total medical costs were lower for both cohorts of members in the second 12-month period following partnership initiation compared with the baseline period.

CONCLUSIONS

Promising trends were observed among members participating in this payer-provider care partnership with respect to both clinical and economic outcomes. This suggests that collaborations with shared incentives may be a valuable approach for patients with ESRD.

Cost-effectiveness analysis of elbasvir-grazoprevir regimen for treating hepatitis C virus genotype 1 infection in stage 4-5 chronic kidney disease patients in France

Objective

To assess the cost-effectiveness of the elbasvir/grazoprevir (EBR/GZR) regimen in patients with genotype 1 chronic hepatitis C virus (HCV) infection with severe and end-stage renal disease compared to no treatment.

Design

This study uses a health economic model to estimate the cost-effectiveness of treating previously untreated and treatment experienced chronic hepatitis C patients who have severe and end stage renal disease with the elbasvir-grazoprevir regimen versus no treatment in the French context. The lifetime homogeneous markovian model comprises of forty combined health states including hepatitis C virus and chronic kidney disease. The model parameters were from a multicentre randomized controlled trial, ANRS CO22 HEPATHER French cohort and literature. 1000 Monte Carlo simulations of patient health states for each treatment strategy are used for probabilistic sensitivity analysis and 95% confidence intervals calculations. The results were expressed in cost per quality-adjusted life year (QALY) gained.

Patients

The mean age of patients in the HEPATHER French cohort was 59.6 years and 56% of them were men. 22.3% of patients had a F0 fibrosis stage (no fibrosis), 24.1% a F1 stage (portal fibrosis without septa), 7.1% a F2 stage (portal fibrosis with few septa), 21.4% a F3 stage (numerous septa without fibrosis) and 25% a F4 fibrosis stage (compensated cirrhosis). Among these HCV genotype 1 patients, 30% had severe renal impairment stage 4, 33% had a severe renal insufficiency stage 5 and 37% had terminal severe renal impairment stage 5 treated by dialysis.

Intervention

Fixed-dose combination of direct-acting antiviral agents elbasvir and grazoprevir compared to no-treatment.

Results

EBR/GZR increased the number of life years (6.3 years) compared to no treatment (5.1 years) on a lifetime horizon. The total number of QALYs was higher for the new treatment because of better utility on health conditions (6.2 versus 3.7 QALYs). The incremental cost-utility ratio (ICUR) was of €15,212 per QALY gained for the base case analysis.

Conclusions

This cost-utility model is an innovative approach that simultaneously looks at the disease evolution of chronic hepatitis C and chronic kidney disease. EBR/GZR without interferon and ribavirin, produced the greatest benefit in terms of life expectancy and quality-adjusted life years (QALY) in treatment-naïve or experienced patients with chronic hepatitis C genotype 1 and stage 4–5 chronic kidney disease including dialysis patients. Based on shape of the acceptability curve, EBR/GZR can be considered cost-effective at a willingness to pay of €20,000 /QALY for patients with renal insufficiency with severe and end-stage renal disease compared to no treatment.

[The Instituto Mexicano del Seguro Social gives dialysis therapies to 426 students without cost]

BACKGROUND

The Instituto Mexicano del Seguro Social (IMSS) is the institution with the greatest health coverage in Mexico. In adherence to existing and committed to provide specialized services to specific populations (vulnerable age groups, such as children and young people in primary, secondary and higher education, productive and without social security educational training), this gives the renal replacement therapy -peritoneal dialysis and hemodialysis- at no cost to students.

METHODS

Cross-sectional and retrospective study conducted from 1 to 30 September 2016; Census Patients with Chronical Renal Failure, sociodemographic and type of therapy are identified; direct costs are estimated.

RESULTS

At 25 August 2016 to 16 426 was addressed to 26 years old, 279 male (65%) and 147 female (35%). The causes IRC were congenital problems 194 (45%), chronic glomerular diseases 111 (26%), diabetes mellitus type 1, 58 (14%), polycystic kidneys 7 (2%) and undetermined causes 56 (13%). 78 patients received CAPD, APD 208, 61 HD and 79 HD IM MS. The average annual investment per patient was 75 827.47 mexican pesos; the costs were in CAPD dialysis modality $ 41 931.20, DPA $ 64 123.20, HD intramural $ 33 301.32 and extramural $ 165 360.00; which generated a cash cost of $ 32 302 503.40 mexican pesos

CONCLUSIONS

These data demonstrate the Institute commitment to society in granting health, preserve life and improve the quality of life of Mexicans and stage of health risk posed by the IRC.

Association of Citizenship Status With Kidney Transplantation in Medicaid Patients

BACKGROUND

Although individuals classified as nonresident aliens, including undocumented immigrants, are entitled to receive emergency dialysis in the United States regardless of their ability to pay, most states do not provide them with subsidized care for maintenance dialysis or kidney transplantation. We explored whether nonresident aliens have similar outcomes to US citizens after receiving kidney transplants covered by Medicaid, a joint federal and state health insurance program.

STUDY DESIGN

Retrospective observational cohort study.

SETTING & PARTICIPANTS

All adult Medicaid patients in the US Renal Data System who received their first kidney transplant from 1990 to 2011.

PREDICTOR

Citizenship status, categorized as US citizen, nonresident alien, or permanent resident.

OUTCOME

All-cause transplant loss.

MEASUREMENTS

HRs and 95% CIs estimated by applying Cox proportional hazards frailty models with transplantation center as a random effect.

RESULTS

Of 10,495 patients, 8,660 (82%) were US citizens, 1,489 (14%) were permanent residents, and 346 (3%) were nonresident aliens, whom we assumed were undocumented immigrants. Nonresident aliens were younger, healthier, receiving dialysis longer, and more likely to have had a living donor. 71% underwent transplantation in California, and 61% underwent transplantation after 2005. Nonresident aliens had a lower unadjusted risk for transplant loss compared with US citizens (HR, 0.48; 95% CI, 0.35-0.65). Results were attenuated but still significant when adjusted for demographics, comorbid conditions, dialysis, and transplant-related factors (HR, 0.67; 95% CI, 0.46-0.94).

LIMITATIONS

Citizenship status was self-reported, possible residual confounding.

CONCLUSIONS

Our study suggests that the select group of insured nonresident aliens who undergo transplantation with Medicaid do just as well as US citizens with Medicaid. Policymakers should consider expanding coverage for kidney transplantation in nonresident aliens, including undocumented immigrants, given the associated high-quality outcomes in these patients.

A strategy to reduce inflammation and anemia treatment's related costs in dialysis patients

This is a post-hoc analysis evaluating erythropoiesis stimulating agents' (ESA) related costs while using an additional ultrafilter (Estorclean PLUS) to produce ultrapure dialysis water located within the fluid pathway after the treatment with reverse osmosis and before the dialysis machine. Twenty-nine patients (19 treated with epoetin alfa and 10 with darboepoetin alfa) were included in the analysis. We showed to gain savings of 210 € per patient (35 € per patient each month) with epoetin alfa during the experimental period of 6 months, compared to the control period and of 545 € per patient (90 € per patient each month) with darboepoetin alfa. Estorclean PLUS had a cost of 600 € (25 € per month per each patient) and was used for 6 months. Intravenous iron therapy with sodium ferrigluconate had a cost of 0,545 €/62,5 mg. In conclusion, during the experimental period with the use of Estorclean, we obtained global savings of 11 € per patient per month with epoetin alfa and 30 € per patient per month with darboepoetin alfa to treat anemia in dialysis patients.

Perspectives from the Kidney Health Initiative on Advancing Technologies to Facilitate Remote Monitoring of Patient Self-Care in RRT

Telehealth and remote monitoring of a patient's health status has become more commonplace in the last decade and has been applied to conditions such as heart failure, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. Conversely, uptake of these technologies to help engender and support home RRTs has lagged. Although studies have looked at the role of telehealth in RRT, they are small and single-centered, and both outcome and cost-effectiveness data are needed to inform future decision making. Furthermore, alignment of payer and government (federal and state) regulations with telehealth procedures is needed along with a better understanding of the viewpoints of the various stakeholders in this process (patients, caregivers, clinicians, payers, dialysis organizations, and government regulators). Despite these barriers, telehealth has great potential to increase the acceptance of home dialysis, and improve outcomes and patient satisfaction while potentially decreasing costs. The Kidney Health Initiative convened a multidisciplinary workgroup to examine the current state of telehealth use in home RRTs as well as outline potential benefits and drawbacks, impediments to implementation, and key unanswered questions.

Medicare Program; End-Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, and End-Stage Renal Disease Quality Incentive Program. Final rule

This rule updates and makes revisions to the end-stage renal disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2018. It also updates the payment rate for renal dialysis services furnished by an ESRD facility to individuals with acute kidney injury (AKI). This rule also sets forth requirements for the ESRD Quality Incentive Program (QIP), including for payment years (PYs) 2019 through 2021.

Projecting prevalence, costs and evaluating simulated interventions for diabetic end stage renal disease in a Canadian population of aboriginal and non-aboriginal people: an agent based approach

BACKGROUND

Diabetes-related end stage renal disease (DM-ESRD) is a devastating consequence of the type 2 diabetes epidemic, both of which disproportionately affect Indigenous peoples. Projecting case numbers and costs into future decades would help to predict resource requirements, and simulating hypothetical interventions could guide the choice of best practices to mitigate current trends.

METHODS

An agent based model (ABM) was built to forecast First Nations and non-First Nations cases of DM-ESRD in Saskatchewan from 1980 to 2025 and to simulate two hypothetical interventions. The model was parameterized with data from the Canadian Institute for Health Information, Saskatchewan Health Administrative Databases, the Canadian Organ Replacement Register, published studies and expert judgement. Input parameters without data sources were estimated through model calibration. The model incorporated key patient characteristics, stages of diabetes and chronic kidney disease, renal replacement therapies, the kidney transplant assessment and waiting list processes, costs associated with treatment options, and death. We used this model to simulate two interventions: 1) No new cases of diabetes after 2005 and 2) Pre-emptive renal transplants carried out on all diabetic persons with new ESRD.

RESULTS

There was a close match between empirical data and model output. Going forward, both incidence and prevalence cases of DM-ESRD approximately doubled from 2010 to 2025, with 250-300 new cases per year and almost 1300 people requiring RRT by 2025. Prevalent cases of First Nations people with DM-ESRD increased from 19% to 27% of total DM-ESRD numbers from 1990 to 2025. The trend in yearly costs paralleled the prevalent DM-ESRD case count. For Scenario 1, despite eliminating diabetes incident cases after 2005, prevalent cases of DM-ESRD continued to rise until 2019 before slowly declining. When all DM-ESRD incident cases received a pre-emptive renal transplant (scenario 2), a substantial increase in DM-ESRD prevalence occurred reflecting higher survival, but total costs decreased reflecting the economic advantage of renal transplantation.

CONCLUSIONS

This ABM can forecast numbers and costs of DM-ESRD in Saskatchewan and be modified for application in other jurisdictions. This can aid in resource planning and be used by policy makers to evaluate different interventions in a safe and economical manner.

A New Statistical Method to Determine the Degree of Validity of Health Economic Model Outcomes against Empirical Data

BACKGROUND

The validation of health economic (HE) model outcomes against empirical data is of key importance. Although statistical testing seems applicable, guidelines for the validation of HE models lack guidance on statistical validation, and actual validation efforts often present subjective judgment of graphs and point estimates.

OBJECTIVES

To discuss the applicability of existing validation techniques and to present a new method for quantifying the degrees of validity statistically, which is useful for decision makers.

METHODS

A new Bayesian method is proposed to determine how well HE model outcomes compare with empirical data. Validity is based on a pre-established accuracy interval in which the model outcomes should fall. The method uses the outcomes of a probabilistic sensitivity analysis and results in a posterior distribution around the probability that HE model outcomes can be regarded as valid.

RESULTS

We use a published diabetes model (Modelling Integrated Care for Diabetes based on Observational data) to validate the outcome "number of patients who are on dialysis or with end-stage renal disease." Results indicate that a high probability of a valid outcome is associated with relatively wide accuracy intervals. In particular, 25% deviation from the observed outcome implied approximately 60% expected validity.

CONCLUSIONS

Current practice in HE model validation can be improved by using an alternative method based on assessing whether the model outcomes fit to empirical data at a predefined level of accuracy. This method has the advantage of assessing both model bias and parameter uncertainty and resulting in a quantitative measure of the degree of validity that penalizes models predicting the mean of an outcome correctly but with overly wide credible intervals.

Annual direct medical costs associated with diabetes-related complications in the event year and in subsequent years in Hong Kong

AIM

To develop models to estimate the direct medical costs associated with diabetes-related complications in the event year and in subsequent years.

METHODS

The public direct medical costs associated with 13 diabetes-related complications were estimated among a cohort of 128 353 people with diabetes over 5 years. Private direct medical costs were estimated from a cross-sectional survey among 1825 people with diabetes. We used panel data regression with fixed effects to investigate the impact of each complication on direct medical costs in the event year and subsequent years, adjusting for age and co-existing complications.

RESULTS

The expected annual public direct medical cost for the baseline case was US$1,521 (95% CI 1,518 to 1,525) or a 65-year-old person with diabetes without complications. A new lower limb ulcer was associated with the biggest increase, with a multiplier of 9.38 (95% CI 8.49 to 10.37). New end-stage renal disease and stroke increased the annual medical cost by 5.23 (95% CI 4.70 to 5.82) and 5.94 (95% CI 5.79 to 6.10) times, respectively. History of acute myocardial infarction, congestive heart failure, stroke, end-stage renal disease and lower limb ulcer increased the cost by 2-3 times. The expected annual private direct medical cost of the baseline case was US$187 (95% CI 135 to 258) for a 65-year-old man without complications. Heart disease, stroke, sight-threatening diabetic retinopathy and end-stage renal disease increased the private medical costs by 1.5 to 2.5 times.

CONCLUSIONS

Wide variations in direct medical cost in event year and subsequent years across different major complications were observed. Input of these data would be essential for economic evaluations of diabetes management programmes.

All-cause costs increase exponentially with increased chronic kidney disease stage

OBJECTIVE

To evaluate the economic impact of chronic kidney disease (CKD) on US health plans.

STUDY DESIGN

A retrospective analysis identified patients with a renin-angiotensin-aldosterone system inhibitor (RAASi) prescription from an electronic medical record (EMR) database (Humedica); those with =90 days in =1 CKD stage were selected based on estimated glomerular filtration rate or diagnosis code, and a cohort on RAASi medications without CKD was selected. Costs for specific services obtained from OptumInsight were applied to services in EMR data of patients aged <65 years (commercial) and =65 years (Medicare). Dialysis costs were excluded.

RESULTS

The study included 106,050 patients with CKD and 56,761 no-CKD controls (90,302 commercial and 72,509 Medicare overall). Mean annualized all-cause costs increased exponentially with advancing stage, from $7537 (no CKD) to $76,969 (CKD stages 4-5) in the commercial group, and $8091 (no CKD) to $46,178 (CKD stages 4-5) in the Medicare group (P <.001; all comparisons with preceding disease stage). Mean costs for end-stage renal disease (ESRD) patients were $121,948 and $87,339 in the commercial and Medicare groups, respectively. Inpatient costs were the largest contributor to total costs, and their relative contribution increased with advancing CKD.

CONCLUSIONS

Cost to US health plans increases exponentially with each CKD stage progression. ESRD costs are even higher. Because readmissions lead to higher costs, efforts to reduce readmissions would result in cost reductions. Furthermore, healthcare reengineering paradigms that manage increasing comorbidities with advancing CKD, including heart failure, diabetes, and hyperkalemia, should offer additional potential for cost reductions.

Ethical issues in dialysis therapy

Treatment for end-stage kidney disease is a major economic challenge and a public health concern worldwide. Renal-replacement therapy poses several practical and ethical dilemmas of global relevance for patients, clinicians, and policy makers. These include how to: promote patients' best interests; increase access to dialysis while maintaining procedural and distributive justice; minimise the influence of financial incentives and competing interests; ensure quality of care in service delivery and access to non-dialytic supportive care when needed; minimise the financial burden on patients and health-care system; and protect the interests of vulnerable groups during crisis situations. These issues have received comparatively little attention, and there is scant ethical analysis and guidance available to decision makers. In this Health Policy, we provide an overview of the major ethical issues related to dialysis provision worldwide, identify priorities for further investigation and management, and present preliminary recommendations to guide practice and policy.

A comprehensive approach to assess the costs of renal replacement therapy for end-stage renal disease in France: the importance of age, diabetes status, and clinical events

OBJECTIVES

In the current pressured economic context, and to continue to treat the growing number of patients with high-quality standards, the first step is to have a better understanding of the costs related to end-stage renal disease (ESRD) treatment according to various renal replacement therapy, age, diabetes status, and clinical events.

METHODS

In order to estimate the direct costs of all adult ESRD patients, according to (RRT) modality, patient condition, and clinical events, data from the French national health insurance funds were used.

RESULTS

The mean monthly costs for the 47,862 stable prevalent patients (73 % of the population) varied substantially according to treatment modality (from 7300€ for in-center hemodialysis to 1100€ for a functioning renal graft) and to clinical event (8300€ for the first month of dialysis, 11,000€ for the last month before death, 22,800€ for the first month after renal transplantation). Mean monthly costs varied according to diabetic status and to age to a lesser extent.

CONCLUSIONS

These results demonstrate, for the first time in France and in Europe, the importance of a dynamic view of renal care and the bias likely when comparing treatments in cross-sectional studies.

Disparities in dialysis allocation: An audit from the new South Africa

End Stage Kidney Disease (ESKD) is a public health problem with an enormous economic burden. In resource limited settings management of ESKD is often rationed. Racial and socio-economic inequalities in selecting candidates have been previously documented in South Africa. New guidelines for dialysis developed in the Western Cape have focused on prioritizing treatment. With this in mind we aimed at exploring whether the new guidelines would improve inequalities previously documented. A retrospective study of patients presented to the selection committee was conducted at Groote Schuur Hospital. A total of 564 ESKD patients presented between 1 January 2008 and 31 December 2012 were assessed. Half of the patients came from low socioeconomic areas, and presentation was late with either overt uremia (n = 181, 44·4%) or fluid overload (n = 179, 43·9%). More than half (53·9%) of the patients were not selected for the program. Predictors of non-acceptance onto the program included age above 50 years (OR 0·3, p = 0·001), unemployment (OR 0·3, p<0·001), substance abuse (OR 0·2, p<0·001), diabetes (OR 0·4, p = 0·016) and a poor psychosocial assessment (OR 0·13, p<0·001). Race, gender and marital status were not predictors. The use of new guidelines has not led to an increase in inequalities. In view of the advanced nature of presentation greater efforts need to be made to prevent early kidney disease, to allocate more resources to renal replacement therapy in view of the loss of young and potentially productive life.

New Opportunities for Funding Dialysis-Dependent Undocumented Individuals

The cost of dialysis for the estimated 6500 dialysis-dependent undocumented individuals with kidney failure in the United States is high, the quality of dialysis care they receive is poor, and their treatment varies regionally. Some regions use state and matched federal funds to cover regularly scheduled dialysis treatments, while others provide treatment only in emergent life-threatening conditions. Nephrologists caring for patients who receive emergent dialysis are tasked with the difficult moral dilemma of determining "who gets dialysis that day." Without a path to citizenship and by exclusion from the federal marketplace exchanges, undocumented individuals have limited options for their treatment. A novel opportunity to provide scheduled dialysis for this population is through the purchase of insurance off the exchange. Plans purchased off the exchange must still abide by the 2014 provision of the Patient Protection and Affordable Care Act, which prohibits insurance companies from denying coverage based on a preexisting health condition. In 2015 and 2016, >100 patients previously receiving only emergent dialysis at the two largest safety-net hospital systems in Texas obtained off-the-exchange commercial health insurance plans. These undocumented patients now receive scheduled dialysis treatments, which has improved their care and quality of life, as well as decompressed the overburdened hospital systems. The long-term sustainability of this option is not known. Socially responsive and visionary policymakers allowing the move into this bold, new direction deserve special appreciation.

Health policies on dialysis modality selection: a nationwide population cohort study

OBJECTIVES

In Taiwan, peritoneal dialysis (PD) and haemodialysis are fully accessible to patients with end-stage renal disease. However, the usage of PD is considered low in Taiwan. Since 2005, 4 major policies have been implemented by Taiwan's Ministry of Health and Welfare, namely a multidisciplinary predialysis care programme and usage increasing the PD incidence as a key performance indicator (KPI) for hospital accreditation, both of which were implemented in 2006; reimbursement of the glucose-free dialysate, icodextrin that was implemented in 2007; and insurance reimbursement for renting automated PD machines that was implemented in 2008. The aim of this study was to analyse the associations between the PD promotional policies and the actual PD selection rates.

SETTING

We analysed data within the Taiwan Renal Registry Data System from 2006 to 2013, focusing on the PD incidence in relation to the timings of the 4 PD promotional policies; then we stratified the results according to age, sex and the presence of diabetes mellitus.

PARTICIPANTS

From 2006 to 2013, 115 565 patients were enrolled in this study. The mean (SD) age of patients on PD was 54.6 (15.7) years.

RESULTS

During the time frame in which the 4 PD promotional policies were implemented, the PD incidence increased from 12.8% in 2006 to 15.1% in 2009. The PD incidence started to decline in 2010 (13.8%) when the hospital accreditation policy was repealed. The 3 remaining policies were weakly associated with the PD incidence. The observational analysis determined that the patients' ages, sexes and diabetes mellitus incidence rates were relatively stable from 2006 to 2013.

CONCLUSIONS

Of the 4 health policies intended to promote PD usage, using increasing the PD incidence as a KPI for hospital accreditation had the strongest association with the PD incidence.

Regional Variations in the Interpretation of the End-Stage Renal Disease Thirty-Month Coordination Period: Potential Implications for Patient Care

Chronic kidney disease is a non-communicable disease that is now well recognized as a major source of premature morbidity and mortality. In general, racial/ethnic minorities in the United States are more likely than non-minority groups to develop end-stage renal disease (ESRD), but paradoxically most have a lower mortality risk. Unlike most minorities, dialysis patients in Puerto Rico have a mortality risk nearly 50% higher than the national average. Multiple factors such as medical conditions, socioeconomic, environmental, and health system factors can influence health outcomes for patients with ESRD. We describe one potential health system factor that may contribute to this finding, a unique interpretation and implementation of the ESRD Medicare Secondary Payer provision in the Commonwealth of Puerto Rico. We conducted a search of regulatory documents and key stakeholder interviews to help envision the potential implications of these differences for dialysis facilities, health care providers, and patients with ESRD.

Medicare Program; Conditions for Coverage for End-Stage Renal Disease Facilities--Third Party Payment. Interim final rule with comment period

This interim final rule with comment period implements new requirements for Medicare-certified dialysis facilities that make payments of premiums for individual market health plans. These requirements apply to dialysis facilities that make such payments directly, through a parent organization, or through a third party. These requirements are intended to protect patient health and safety; improve patient disclosure and transparency; ensure that health insurance coverage decisions are not inappropriately influenced by the financial interests of dialysis facilities rather than the health and financial interests of patients; and protect patients from mid-year interruptions in coverage.

Medicare Program; End-Stage Renal Disease Prospective Payment System, Coverage and Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program, Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding Program Bid Surety Bonds, State Licensure and Appeals Process for Breach of Contract Actions, Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding Program and Fee Schedule Adjustments, Access to Care Issues for Durable Medical Equipment; and the Comprehensive End-Stage Renal Disease Care Model. Final rule

This rule updates and makes revisions to the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for calendar year 2017. It also finalizes policies for coverage and payment for renal dialysis services furnished by an ESRD facility to individuals with acute kidney injury. This rule also sets forth requirements for the ESRD Quality Incentive Program, including the inclusion of new quality measures beginning with payment year (PY) 2020 and provides updates to programmatic policies for the PY 2018 and PY 2019 ESRD QIP. This rule also implements statutory requirements for bid surety bonds and state licensure for the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP). This rule also expands suppliers' appeal rights in the event of a breach of contract action taken by CMS, by revising the appeals regulation to extend the appeals process to all types of actions taken by CMS for a supplier's breach of contract, rather than limit an appeal for the termination of a competitive bidding contract. The rule also finalizes changes to the methodologies for adjusting fee schedule amounts for DMEPOS using information from CBPs and for submitting bids and establishing single payment amounts under the CBPs for certain groupings of similar items with different features to address price inversions. Final changes also are made to the method for establishing bid limits for items under the DMEPOS CBPs. In addition, this rule summarizes comments on the impacts of coordinating Medicare and Medicaid Durable Medical Equipment for dually eligible beneficiaries. Finally, this rule also summarizes comments received in response to a request for information related to the Comprehensive ESRD Care Model and future payment models affecting renal care.

Cost-Effectiveness of High Dose Hemodialysis in Comparison to Conventional In-Center Hemodialysis in the Netherlands

INTRODUCTION

In the Netherlands, the current standard of care for treating patients with end-stage renal disease is three sessions of in-center hemodialysis (conventional ICHD). However, the literature indicates that high dose hemodialysis (high dose HD) may provide better health outcome such as survival and quality of life. The objective of this study was to determine the cost-effectiveness of high dose HD, both in-center and at home, in comparison to conventional ICHD from a Dutch payer's perspective over a 5 year period. Additionally, the cost-effectiveness of conventional HD at home in comparison to conventional ICHD will be analysed.

METHODS

A Markov model was developed assuming 28-day treatment cycles and was populated with data from Dutch and international renal registries, official tariffs and medical literature. Univariable and probabilistic sensitivity analyses were performed to test the robustness of the results.

RESULTS

Using publicly available tariffs from the Dutch Healthcare Authority (Nederlandse Zorgautoriteit) of 2015, doing high dose ICHD instead of conventional ICHD shows an incremental cost-effectiveness ratio (ICER) of €275,747 per quality-adjusted life year (QALY) gained. In contrast, the ICER of high dose HD at home in comparison to conventional ICHD is €3248 per gained QALY. The final analysis shows that conventional HD at home is less costly per patient (-€3063) than conventional ICHD and results in health benefit improvement (+0.249 QALYs), and is therefore regarded as cost saving.

CONCLUSION

Treating dialysis patients with conventional HD at home shows to be cost saving in comparison to conventional ICHD. However, the magnitude of clinical benefit of high dose HD at home is over two times greater than the clinical benefit of conventional HD at home. According to our analysis, from a payer's perspective, high dose HD should be offered as a home therapy to obtain its clinical benefits in a cost-effective manner. Future research should consider our findings alongside societal factors, such as patient preference, monitoring cost for the home patient, productivity loss and capacity.

FUNDING

Baxter BV, The Netherlands.

Healthcare costs in chronic kidney disease and renal replacement therapy: a population-based cohort study in Sweden

OBJECTIVE

To compare healthcare costs in chronic kidney disease (CKD) stage 4 or 5 not on dialysis (estimated glomerular filtration rate <30 mL/min/1.73m²), peritoneal dialysis, haemodialysis and in transplanted patients with matched general population comparators.

DESIGN

Population-based cohort study.

SETTING

Swedish national healthcare system.

PARTICIPANTS

Prevalent adult patients with CKD 4 or 5 (n=1046, mean age 68 years), on peritoneal dialysis (n=101; 64 years), on haemodialysis (n=460; 65 years) and with renal transplants (n=825; 52 years) were identified in Stockholm County clinical quality registers for renal disease on 1 January 2010. 5 general population comparators from the same county were matched to each patient by age, sex and index year.

PRIMARY AND SECONDARY OUTCOME MEASURES

Annual healthcare costs in 2009 incurred through inpatient and hospital-based outpatient care and dispensed prescription drugs ascertained from nationwide healthcare registers. Secondary outcomes were annual number of hospital days and outpatient care visits.

RESULTS

Patients on haemodialysis had the highest mean annual cost (€87 600), which was 1.49 (95% CI 1.38 to 1.60) times that observed in peritoneal dialysis (€58 600). The mean annual cost was considerably lower in transplanted patients (€15 500) and in the CKD group (€9600). In patients on haemodialysis, outpatient care costs made up more than two-thirds (€62 500) of the total, while costs related to fluids ($29 900) was the largest cost component in patients on peritoneal dialysis (51%). Compared with their matched general population comparators, the mean annual cost (95% CI) in patients on haemodialysis, peritoneal dialysis, transplanted patients and patients with CKD was 45 (39 to 51), 29 (22 to 37), 11 (10 to 13) and 4.0 (3.6 to 4.5) times higher, respectively.

CONCLUSIONS

The mean annual costs were ∼50% higher in patients on haemodialysis than in those on peritoneal dialysis. Compared with the general population, costs were substantially elevated in all groups, from 4-fold in patients with CKD to 11, 29 and 45 times higher in transplanted patients and patients on peritoneal dialysis and haemodialysis, respectively.

Supportive Care: Economic Considerations in Advanced Kidney Disease

Kidney supportive care describes multiple interventions for patients with advanced CKD that focus on improving the quality of life and addressing what matters most to patients. This includes shared decision making and aligning treatment plans with patient goals through advance care planning and providing relief from pain and other distressing symptoms. Kidney supportive care is an essential component of quality care throughout the illness trajectory. However, in the context of limited health care resources, evidence of its cost-effectiveness is required to support decisions regarding appropriate resource allocation. We review the literature and outline the evidence gaps and particular issues associated with measuring the costs, benefits, and cost-effectiveness of kidney supportive care. We find evidence that the dominant evaluative framework of a cost per quality-adjusted life year may not be suitable for evaluations in this context and that relevant outcomes may include broader measures of patient wellbeing, having care aligned with treatment preferences, and family satisfaction with the end of life care experience. To improve the evidence base for the cost-effectiveness of kidney supportive care, large prospective cohort studies are recommended to collect data on both resource use and health outcomes and should include patients who receive conservative kidney management without dialysis. Linkage to administrative datasets, such as Medicare, Hospital Episode Statistics, and the Pharmaceutical Benefits Scheme for prescribed medicines, can provide a detailed estimate of publicly funded resource use and reduce the burden of data collection for patients and families. Longitudinal collection of quality of life and functional status should be added to existing cohort or kidney registry studies. Interventions that improve health outcomes for people with advanced CKD, such as kidney supportive care, not only have the potential to improve quality of life, but also may reduce the high costs associated with unwanted hospitalization and intensive medical treatments.

The Economics of Kidney Transplantation versus Hemodialysis

Using 1998 data for 8 transplantation centers located in New York City, this study found that kidney transplantation was a more cost-effective treatment than hemodialysis for the Medicare program. The initially higher costs of transplantation were fully recouped by Medicare 2 years and 10 months after surgery. For persons who are eligible for Medicare solely due to their end-stage renal disease status, transplantation would generate average monthly savings of $3800 over dialysis for the 2 years following the break-even point. For those eligible for reasons other than end-stage renal disease, for example, the aged, the average savings would be $2400. The savings difference arises because Medicare coverage for immunosuppressants for the former group ends 36 months after transplantation.