A look back, and getting positioned for the future

When NN&I reviewed the data from our first ranking of U.S. dialysis providers 20 years ago, the headline read, “The changing face of renal care providers: Who will dominate the market?” The article at the time talked about a “buying frenzy” by mid-sized organizations that signed up investors or went public to raise cash and buy clinics. “We continue to benefit from a motivated seller environment and the strongest acquisition pipeline we have seen in years,” noted Renal Treatment Center chairman and president Robert L. Mayer, Jr. RTC was ranked fourth largest at the time with 4,460 patients.

Renal Treatment Centers, REN Centers, Total Renal Care, National Nephrology Associates, Caremark Nephrology––all names of the past that have been bought and sold over the last two decades. The spread in the number of patients among the 10 largest providers in that first ranking was 40,000 (National Medical Care) to 1,035 patients (RenalWest); in this year’s 20th annual ranking, it ranges from a whopping 172,006 patients (Fresenius Medical Care North America) down to 1,563 from new entry Northwest Kidney Centers. The good news is that those small providers are still around. Likewise, Satellite Healthcare, a midsize provider, along with Dialysis Clinic Inc., the only two “survivors” from that 1995 survey, have more than doubled their patient populations.

The direction for home therapy

We didn’t track the use of home hemodialysis in 1995, just the number of peritoneal dialysis patients per provider. The total PD population in 1995 was 11,954, or about 15% of the 75,678 total patient population represented by the 10 largest providers. We know the percentage of patients on home therapies has crumbled over the last decade, but financial incentives put in place by the ESRD Program have led to a renewed interest. Today, the home population represents about 11% of the total patient population among the providers in our survey. Satellite and Northwest Kidney Centers continue to lead the way in the number of patients dialyzing at home. Overall, the percentage of patients on home therapies has been growing steadily in this group since 2011 (see Figure 3). Also of note: providers—or perhaps patients—seem to be losing interest in in-center nocturnal hemodialysis programs. They can be costly to staff and a minimum number of patients is needed to keep a

shift open.

The steady rebirth of the home dialysis population is long coming; the most crucial part of that resurgence, however, is the outcomes. About 75% of the providers in our

ranking this year said they were tracking PD patients who had urgent starts, a practice that is gaining a lot of attention (see our June NN&I cover story on this topic). Making any home therapy successful means a strong technique survival: will patients stay on long enough to appreciate the benefits?

But the increase in use of home therapies (eight of the 10 providers in this year’s survey added 5,212 home patients) varied by modality. The number of HHD patients were down at FMCNA compared to our 2013 survey and up at DaVita; all providers showed an increase in PD patients. The incentives offered by Medicare play an

important role in the future of the integrated care environment, where providers and clinicians help patients choose a therapy that leads to outcomes that are cost effective. In their introduction of the Comprehensive ESRD Care Initiative demonstration, officials from the Centers for Medicare and Medicaid Services made the point that they hoped the demo would lead to providers increasing the number of patients on home dialysis.

Looking ahead

What can we expect in the next 20 years? It’s clear that renal economics will play a part to determining who the providers are—and how dialysis will be delivered. -by Mark Neumann

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