Data identify influence of economic impact on dialysis modality choice in US
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KANSAS CITY, Mo. — The three modalities of dialysis show different economic impacts that influence which modality a patient chooses, according to research presented at The Annual Dialysis Conference.
“There are three modalities, at least by my taxonomy: in-center hemodialysis; home hemodialysis; and peritoneal dialysis,” Eric D. Weinhandl, PhD, MS, a senior director of epidemiology and biostatistics at Fresenius Medical Care North America and adjunct assistant professor at the department of pharmaceutical care and health systems at the University of Minnesota, said during his presentation. “But the reality with each of these modalities is that there are a lot of factors that dictate the details and dictate the supply cost.”
Health insurance is an important factor in cost of modalities, he noted. Medicare fee-for-service is the most popular payer with 60% of patients enrolled. Medicare Part A hospitalization is a large impact to cost-effectiveness for modality in the United States due to cardiovascular hospitalization in the in-center population and infection-related hospitalization in home hemodialysis. Hospitalization drive 35% to 40% of total expenditures.
Outside of the United States, Weinhandl noted that hospitalization is not impactful in its contribution to total cost. In the United States, it costs a lot of money for admission and the dependence of the cost profile of the modality in this country is larger than that of other high-end countries.
According to Weinhandl, frequency of dialysis matters whether it is three times a week or six times a week. The cost profile changes depending on utilization and deployment of home hemodialysis. Home hemodialysis has a better cost profile when patient frequency is higher. Peroneal dialysis may lower societal costs, but it is reliant on reimbursement, he said.
Nocturnal hemodialysis is a dominant therapy in comparison to conventional hemodialysis, but different scenarios show changes in cost-effectiveness of the modality. Additional hemodialysis sessions increase cost due to Medicare accruing more expenditures by paying for more dialysis sessions, he noted.
One of the other scenarios Weinhandl presented involved technique failure rate. The amount of time a patient spends on home hemodialysis before converting back to conventional incenter hemodialysis influences cost-effectiveness, he said.
“We are generating a tremendous cost to Medicare’s system by way of technique failure being a bit of a disadvantage for PD patients,” Weinhandl said.
Training costs can also lead to a large expenditure and are different between modalities. Training time with the next-stage home hemodialysis system is shorter and, costs less than the conventional home hemodialysis system, he said. This relates to the technique failure rate. If patients drop out of home hemodialysis or PD quickly, then the system accrues larger expenditures from training and transitioning.
“It’s unclear to me that any one dialysis modality is clearly superior in its economic impact,” Weinhandl said. “Medicare Part A spending in this country is hugely important and the reimbursement rates in total for facility [hemodialysis] HD, home HD and PD is important. Cost profile for home HD hinges on these three factors: payment for extra sessions – if it exists at all; cardiovascular risk reduction has to be accomplished – if you don’t then there are no savings; [and] infectious complications, which have the potential to drive up costs.” – by Erin T. Welsh
Reference:
Weinhandl ED. Economic impact: Is this a determination for choice of dialysis? Presented at: The Annual Dialysis Conference; Feb. 8-11, 2020; Kansas City, Missouri.
Disclosure: Weinhandl reports he is a member of the Home Dialyzors United Advisory Board and the National Quality Forum Scientific Methods Panel.