Mortality at For-Profit Versus Not-For-Profit Hemodialysis Centers: A Systematic Review and Meta-analysis

Privatization and Oligopolies of the Renal Replacement Therapy Sector on Contemporary Capitalism: A Systematic Review and the Brazilian Scenario

Worldwide the assistance on renal replacement therapy (RRT) is carried out mainly by private for-profit services and in a market with increase in mergers and acquisitions. The aim of this study was to conduct an integrative systematic review on privatization and oligopolies in the RRT sector in the context of contemporary capitalism. The inclusion criteria were scientific articles without language restrictions and that addressed the themes of oligopoly or privatization of RRT market. Studies published before 1990 were excluded. The exploratory search for publications was carried out on February 13, 2024 on the Virtual Health Library Regional Portal (VHL). Using the step-by-step of PRISMA flowchart, 34 articles were retrieved, of which 31 addressed the RRT sector in the United States and 26 compared for-profit dialysis units or those belonging to large organizations with non-profit or public ones. The main effects of privatization and oligopolies, evaluated by the studies, were: mortality, hospitalization, use of peritoneal dialysis and registration for kidney transplantation. When considering these outcomes, 19 (73%) articles showed worse results in private units or those belonging to large organizations, six (23%) studies were in favor of privatization or oligopolies and one study was neutral (4%). In summary, most of the articles included in this systematic review showed deleterious effects of oligopolization and privatization of the RRT sector on the patients served. Possible explanations for this result could be the presence of conflicts of interest in the RRT sector and the lack of incentive to implement the chronic kidney disease care line. The predominance of articles from a single nation may suggest that few countries have transparent mechanisms to monitor the quality of care and outcomes of patients on chronic dialysis.

Profits over care? An analysis of the relationship between corporate capitalism in the healthcare industry and cancer mortality in the United States

The characteristic features of 21st-century corporate capitalism - monopoly and financialization - are increasingly being recognized by public health scholars as undermining the foundations of human health. While the "vectors" through which this is occurring are well known - poverty, inequality, climate change among others - locating the root cause of this process in the nature and institutions of contemporary capitalism is relatively new. Researchers have been somewhat slow to study the relationship between contemporary capitalism and human health. In this paper, we focus on one of the leading causes of death in the United States; cancer, and empirically estimate the relationship between various measures of financialization and monopoly in the US healthcare system and cancer mortality. The measures we focus on are for the hospital industry, the health insurance industry, and the pharmaceutical industry. Using a fixed effects model with different specifications and control variables, our analysis is at the state level for the years 2012-2019. These variables include data on population demographic controls, social and economic factors, and health behavior and clinical care. We compare Medicaid expansion states with non-Medicaid expansion states to investigate variations in state-level funded health insurance coverage. The results show a statistically significant positive correlation between the HHI index in the individual healthcare market and cancer mortality and the opioid dispensing rate and cancer mortality.

Association Between Dialysis Facility Ownership and Mortality Risk in Children With Kidney Failure

Importance

In adults, treatment at profit dialysis facilities has been associated with a higher risk of death.

Objective

To determine whether profit status of dialysis facilities is associated with the risk of death in children with kidney failure treated with dialysis and whether any such association is mediated by differences in access to transplant.

Design, Setting, and Participants

This retrospective cohort study reviewed US Renal Data System records of 15 359 children who began receiving dialysis for kidney failure between January 1, 2000, and December 31, 2019, in US dialysis facilities. The data analysis was performed between May 2, 2022, and June 15, 2023.

Exposure

Time-updated profit status of dialysis facilities.

Main Outcomes and Measures

Adjusted Fine-Gray models were used to determine the association of time-updated profit status of dialysis facilities with risk of death, treating kidney transplant as a competing risk. Cox proportional hazards regression models were also used to determine time-updated profit status with risk of death regardless of transplant status.

Results

The final cohort included 8465 boys (55.3%) and 6832 girls (44.7%) (median [IQR] age, 12 [3-15] years). During a median follow-up of 1.4 (IQR, 0.6-2.7) years, with censoring at transplant, the incidence of death was higher at profit vs nonprofit facilities (7.03 vs 4.06 per 100 person-years, respectively). Children treated at profit facilities had a 2.07-fold (95% CI, 1.83-2.35) higher risk of death compared with children at nonprofit facilities in adjusted analyses accounting for the competing risk of transplant. When follow-up was extended regardless of transplant status, the risk of death remained higher for children treated in profit facilities (hazard ratio, 1.47; 95% CI, 1.35-1.61). Lower access to transplant in profit facilities mediated 67% of the association between facility profit status and risk of death (95% CI, 45%-100%).

Conclusions and Relevance

Given the higher risk of death associated with profit dialysis facilities that is partially mediated by lower access to transplant, the study's findings indicate a need to identify root causes and targeted interventions that can improve mortality outcomes for children treated in these facilities.

Risk of Death among Dialysis Patients Treated at Hospital-Affiliated versus Free-Standing Facilities in the United States

Receipt of dialysis at hospital-affiliated facilities was associated with a higher risk of mortality compared with treatment at free-standing dialysis facilities. The differential mortality risk in free-standing versus hospital-affiliated facilities was more pronounced in non-Hispanic Black and Asian patients compared with other racial/ethnic groups.

Century-Long Trends in the Financing and Ownership of American Health Care

Policy Points Over the past century, the tax-financed share of health care spending has risen from 9% in 1923 to 69% in 2020; a large part of this tax financing is now the subsidization of private health insurance. For-profit ownership of health care facilities has also increased in recent decades and now predominates for many health subsectors. A rising share of physicians are now employees. US health care is, increasingly, publicly financed yet investor owned, a trend that has been accompanied by rising medical costs and, in recent years, stagnating or even worsening population health. A reconsideration of US health care financing and ownership appears warranted.

CONTEXT

Who pays for health care-and who owns it-determine what care is delivered, who receives it, and who profits from it. We examined trends in health care ownership and financing over a century.

METHODS

We used multiple historical and current data sources (including data from the American Medical Association, the American Hospital Association, government publications and surveys, and analyses of Medicare Provider of Services files) to classify health care provider ownership as: public, private (for-profit), and private (not-for-profit). We used US Census data to classify physicians' employers as public, not-for-profit, or for-profit entities or "self-employed." We combined estimates from the official National Health Expenditures Accounts with other data sources to determine the public vs. private share of health care spending since 1923; we calculated a "comprehensive" public share metric that accounted for public subsidization of private health expenditures, mostly via the tax exemption for employer-sponsored insurance plans or government purchase of such plans for public employees.

FINDINGS

For-profit ownership of most health care subsectors has risen in recent decades and now predominates in several (including nursing facilities, ambulatory surgical facilities, dialysis facilities, hospices, and home health agencies). However, most community hospitals remain not-for-profit. Additionally, over the past century, a growing share of physicians identify as employees. Meanwhile, the comprehensive taxpayer-financed share of health care spending has increased dramatically from 9% in 1923 to 69% in 2020, with taxpayer-financed subsidies to private expenditures accounting for much of the recent growth.

CONCLUSIONS

American health care is increasingly publicly financed yet investor owned, a trend accompanied by rising costs and, recently, worsening population health. A reassessment of the US mode of health care financing and ownership appears warranted.

Market Consolidation and Innovation in US Dialysis

While patients with end-stage kidney disease have benefited from innovations in clinical therapeutics and care delivery, these changes have been primarily incremental and have not fundamentally transformed care delivery. Dialysis markets are highly concentrated, which may impede innovation. Unique features of the dialysis industry that have contributed to consolidation can help to explain links between consolidation and innovation. We discuss these unique features and then provide a framework for considering the effects of consolidation on innovation in dialysis that focuses on the following economic considerations: (1) industry characteristics, composition, and stage of consolidation, (2) innovation characteristics and relative profitability, (3) the role of government regulation, and (4) innovation from smaller providers and new entrants. We present examples of how these considerations have influenced the adoption of alternative dialysis technologies such as peritoneal dialysis and erythropoietin-stimulating agents, and we discuss how consolidated markets can both help and hinder recent policy initiatives to transform dialysis care delivery. Only by considering these important drivers of consolidation, future efforts can be successful in transforming end-stage kidney disease care.

Effect of profit status in facilities on the mortality of patients on long-term haemodialysis: a nationwide cohort study

OBJECTIVES

Over the past two decades, debates on whether the profit status of dialysis facilities influences patient prognosis have been popular in the USA. Taiwan is one of the regions with the highest rate per capita of kidney replacement therapy worldwide, but no similar research has been conducted to date. This is the first study to address this issue.

DESIGN

This was a nationwide retrospective cohort study based on the Taiwan Renal Registry Data System.

SETTING

Patients were categorised into two groups based on the profit status (for-profit, not-for-profit (NFP)) of dialysis facilities, with 31 350 patients in each group. The patients were followed up from 2005 to 2012.

PARTICIPANTS

Patients with uraemia who underwent long-term haemodialysis in private dialysis facilities and public facilities were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

Survival analyses were performed to compare prognosis between the two groups. Adjustments to patients' basic profile, and facilities' geographical distribution, level, and length of ownership were carried out to minimise possible confounding effects.

RESULTS

Analysis revealed that NFP dialysis facilities had better outcomes (HR=0.91, 95% CI (0.89 to 0.93)). A favourable effect remains with the adjustment of the facilities' level, geographical distribution (HR=0.89, 95% CI (0.86 to 0.93)) or length of ownership (HR=0.95, 95% CI (0.89 to 0.95)). Survival analysis based on the geographical distribution and level of facilities was also conducted, which showed better prognosis in medical centres in the six municipalities, whereas worse prognosis was found in local hospitals not located in these municipalities.

CONCLUSION

Our findings suggest that in contemporary settings in Taiwan, treatment at NFP dialysis facilities was associated with a better prognosis. The results should be interpreted with caution since the possibility of residual confounding effects and uncertainty of casual relations exist due to the nature of observational studies.