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ED visits for dialysis by uninsured patients contribute to system burden
Uninsured patients with ESRD who visited Texas emergency departments for hemodialysis treatments contributed to high hospital costs and increased strain on the health care system, according to an analysis of 2017 statewide hospital data.
“Patients with end-stage renal disease require regular hemodialysis (HD) treatment, which is nearly universally covered by Medicare in the United States,” Julianna West, BS, of the department of emergency medicine at McGovern Medical School, the University of Texas Health Science Center at Houston, and colleagues wrote in a research letter. “However, Medicare coverage is not available for individuals who are not U.S. citizens or permanent residents. For many uninsured individuals with ESRD, intermittent dialysis through the emergency department (ED) is the sole treatment option.”
They argued that when this is the only means to access treatment, already overcrowded EDs are subject to higher patient volume, hospital dialysis resources may be taxed and health care costs rise. Furthermore, they wrote, while a scheduled outpatient session costs $250, a visit to the ED for hemodialysis costs approximately $2,000.
To more fully examine the health care burden due to lack of insurance, researchers identified 10,390 ED visits by uninsured patients and 23,439 visits by insured patients who required hemodialysis (limiting the analysis to a length-of-stay of 1 day or less to ensure the visit was “most likely associated with HD for an acute indication”).
They found the Arlington and Houston regions had the most uninsured ED visits for hemodialysis (66.1% and 20.4% of total visits, respectively), and uninsured patients were more likely to be younger and to be white or Hispanic.
Total hospital costs for uninsured visits were determined to be $21,837.047.40.
“To our knowledge, these are the largest estimates of the statewide burden of uninsured HD,” the researchers wrote. “... In addition to increasing patient numbers and cost, uninsured HD-associated ED visits cause health care system strain because the determination of the need for HD often requires additional diagnostic tests, and individuals with ESRD not undergoing regular HD often present in clinical crisis, requiring significant inpatient stabilizing care in addition to HD.”
As a cost-effective alternative, they suggested providing scheduled or after-hours outpatient hemodialysis sessions to uninsured patients. – by Melissa J. Webb
Disclosures: West reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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In the United States, patients with ESKD and without U.S. residency status are mostly dialyzed in the emergency department because they cannot secure an outpatient maintenance dialysis schedule. It has been estimated that over 6,000 undocumented immigrants with ESKD live in the United States. Prior studies have shown a higher mortality risk, up to 4.6-fold, for patients dialyzing as emergency-only vs. scheduled sessions. 1,2
The hot button issue, often mischaracterized as “compassion dialysis,” has squarely placed an ethical and financial burden on the clinicians, hospital administrators and policy makers. As clinicians, we have taken an oath to provide a standard of care to each patient, which is at direct odds to an emergency-only dialysis policy. For many decades, this ethical dilemma has been politically charged and invisible to the general public. However, in recent years there has been more focus and discussion on the economic strain placed on health systems with an “emergency only” dialysis policy.
Building on recent studies, West and colleagues used a robust statewide data set to perform an analysis over a 12-month period to identify ED utilization for hemodialysis in an uninsured population. A large proportion of these visits by the uninsured in Texas were those of younger age, ethnically Hispanic, and white race. It is reasonable to assume a significant portion of the visits were from undocumented ESKD patients. The overall annual financial burden was estimated at $21 million by the authors, who correctly concluded that more creative and fiscal responsible solutions are needed to address this long-standing problem.
In fact, some undocumented patients with ESRD can receive scheduled dialysis through state or local funding in the United States. For instance, in California these patients receive outpatient sessions through emergency medical care, but barriers persist to timely central venous catheter removal and access to transplantation. At our medical center, we have employed a “home first” approach via peritoneal dialysis or home hemodialysis to facilitate the transition to the outpatient setting. This is another strategy as home therapies have been cost-effective in reducing hospital utilization and preserving employment status compared to conventional in-center dialysis.
As a kidney community, we have an opportunity to advocate for solutions and programs to address the policies regarding the undocumented ESRD patient population. Maintenance dialysis therapy is not an elective procedure, it is life sustaining. A call to action is in order to address the disparity at each local and state level.
References
1. Kieu N, et al. JAMA Intern Med. 2018;doi:10.1001/jamainternmed.2018.5866
2. Martin M. JAMA Intern Med. 2018;doi:10.1001/jamainternmed.2018.5847
Department of medicine, Division of nephrology
UC Davis School of Medicine
Sacramento, California
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