Assessment of Spending for Patients Initiating Dialysis Care

Abstract

ImportanceDespite a widespread belief that private insurers spend large amounts on health care for enrollees receiving dialysis, data limitations over the past decade have precluded a comprehensive analysis of the topic.ObjectiveTo examine the amount and types of increases in health care spending for privately insured patients associated with initiating dialysis care.Design, Setting, and ParticipantsA cohort study covering calendar years 2012 to 2019 included patients with kidney failure who had employer-sponsored insurance for 12 months following dialysis initiation. Data analysis was performed from August 27, 2021, to August 18, 2022. The data cover the entirety of the US and were obtained from the Health Care Cost Institute. The data include all medical claims for enrollees in employer-sponsored health insurance plans offered by multiple major health care insurers within the US. Participants included patients younger than 65 years who were continuously enrolled in these plans in the 12 months before and after their first claim for dialysis care. Patients also had to have nonmissing documented key characteristics, such as sex, race and ethnicity, and health characteristics.ExposuresA claim for dialysis care.Main Outcomes and MeasuresOut-of-pocket, inpatient, outpatient, physician services, prescription medication, and total health care spending. The hypothesis tested was formulated before data collection.ResultsThe sample included 309 800 enrollee-months, which was a balanced panel of 25 months for 12 392 enrollees. At baseline, 7534 patients (61%) were male, 5415 (44%) were aged 55 to 64 years, and patients had been enrolled with their insurer for a mean of 30 months (95% CI, 29.9-30.1 months). In the 12 months before initiating dialysis care, total monthly health care spending was $5025 per patient per month (95% CI, $4945-$5106). Dialysis care initiation was associated with an increase in total monthly spending of $14 685 (95% CI, $14 413-$14 957). This increase occurred across all spending categories (dialysis, nondialysis outpatient, inpatient, physician services, and prescription drugs). Monthly patient out-of-pocket spending increased by $170 (95% CI, $162-$178). These spending increases occurred abruptly, beginning about 2 months before dialysis initiation, and remained increased for the subsequent 12 months.Conclusions and RelevanceIn this cohort study, evidence that private insurers experience significant, sustained increases in spending when patients initiated dialysis was noted. The findings suggest that proposed policies aimed at limiting the amount dialysis facilities charge private insurers and the enrollees has the potential to reduce health care spending in this high-cost population.

Variations in Payment for Dialysis—Implications for Policy and Practice

“…Under the updated strategic goals of the Center for Medicare and Medicaid Innovation for the coming decade, developing multipayer alignment has been highlighted as a key to achieving system-wide transformation . The work by League and colleagues, along with the other literature described herein, strongly suggests that dialysis should maintain its status as a leading laboratory for building and testing payment system reforms.…”

“…The article by League and colleagues notes that, in their study, spending for patients with employer-sponsored health insurance increased by more than $14 000 per month in the year following the initiation of dialysis, and the level of spending more than doubled Medicare fee-for-service (FFS) spending for the care of patients receiving dialysis. Although spending for all major categories of care increased with initiation of dialysis, spending for the dialysis treatments themselves, which averaged about $10 000 per month, dominated the increase.…”

“…This issue has received considerable attention in the context of the individual market, where dialysis facilities have been accused of supporting premium payments to steer patients into higher paying plans, and Trish and colleagues noted that even shifting a relatively small number of such patients could meaningfully increase premiums in that market. As noted by League and colleagues, it is not clear whether such efforts are underway to encourage patients to remain in the employer-sponsored market rather than switching to Medicare coverage. Currently, patients with kidney failure who were not already Medicare eligible face a 3-month waiting period after the initiation of in-center dialysis (waived for those receiving home dialysis) followed by a 30-month period during which the employer-sponsored plan remains primary if employer coverage is maintained.…”

Diagnosing and Treating IgAN: Steroids, Budesonide, or Maybe Both?

“…Moreover, when a patient experiences advanced kidney disease; then they also have increased morbidity, which means increased costs for the health system. For example, during the last 12 months before starting dialysis therapy, it was calculated that the mean costs were USD 5.025 per patient per month [ 53 ]. In conclusion, budesonide treatment is definitely not a cheap treatment, but it can provide a positive long-term financial benefit.…”

Taurolidine and Heparin as Catheter Lock Solution for Central Venous Catheters in Hemodialysis

“…Vascular access creation and care account for a large proportion of the costs associated with initiating hemodialysis. 80,81 In one analysis, initial hemodialysis with a CVC resulted in disproportionate costs in the 12 months after starting hemodialysis, and it is well established that patients on hemodialysis with CVC have significantly higher rates of CRBSI compared with other types of vascular access. 2,4 , 82 The higher costs among patients starting with CVC access are often attributable to increased hospitalization among this cohort, with infection being a leading cause of hospitalization.…”