New Study Suggests Peritoneal Dialysis May Offer Significant Savings to Medicare

New Study Suggests Peritoneal Dialysis May Offer Significant Savings to Medicare

May 13, 2009

by Astrid Fiano, DOTmed News Writer

The Clinical Therapeutics Journal is publishing a new paper, "The Financial Implications for Medicare of Greater Peritoneal Dialysis Use" by Nancy Neil, PhD, Steve Guest, MD, and several associates. The paper details the use of in-home versus in-center dialysis, including the patterns of dialysis utilization and the results of a budget-impact analysis that indicate if the peritoneal dialysis (PD) share of total dialysis were to increase to 15%, Medicare could yield over one billion dollars in savings over five years.

Dr. Steve Guest, Medical Affairs, Baxter Healthcare, Renal Division, McGaw Park, IL, spoke to DOTmed about the issues and findings in the paper. Dr. Guest first explained that providing care to patients with end stage renal disease (ESRD) is very costly due to the therapy itself but also for the care required to manage the oftentimes concurrent advanced co-morbidities. The overall impact to Medicare is significant as the ESRD Medicare patients represent less than 1% of Medicare enrollees but consume approximately 7% of Medicare resources as measured by payments for medical care billed to Medicare in a given calendar year.

"However, in reality," Dr. Guest said, "the differences in Medicare expenditures between peritoneal dialysis and in-center hemodialysis are very complex with resources being applied to a variety of cost centers."

For example, Dr. Guest described peritoneal dialysis as being most dependent upon disposable resources such as the dialysis solutions and supplies, used to perform the therapy at home. By comparison, in-center hemodialysis is most dependent upon fixed resources, in which investments have been made in bricks and mortar facilities, water treatment capabilities, hemodialysis machines and in-center staffing requirements. "The cost of an unused investment is high and so as not to waste those investments, they must be used to repay the capital outlay." The article is an analysis of these more comprehensive fixed resources used for in-center hemodialysis that include:

-- the facilities in which the hemodialysis is performed;
--the capital investment in the machines themselves;
--the supporting equipment necessary to treat municipal water to become medical grade water and the equipment needed to prepare the dialysate from this treated water;
--ongoing maintenance of the facilities and machines;
-- health personnel, including nurses, technicians, medical assistants, receptionists, etc.

PD does not have the same requirements for a special facility as the home is the site of care. However, Dr. Guest points out that while there is less of a capital investment for peritoneal dialysis, there are significant costs for PD therapy nonetheless: "These costs impact the dialysis providers if they are supplying the patient's dialysis supplies for peritoneal dialysis. But other economies can be realized with home therapy, such as a ratio of 20 patients to 25 patients per nurse for peritoneal dialysis compared to four to six patients per staff member for in-center hemodialysis."

Dr. Guest further detailed the findings regarding the differences in spending. "The differences in spending for hospitalization, outpatient use of erythropoiesis stimulating agents, vitamin D injectables, iron and vascular access reveal that the medical care provided to patients receiving in-center hemodialysis is more costly than that provided to patients on the home-based peritoneal dialysis therapy". Additionally, transportation costs were analyzed as in-center therapy such as hemodialysis requires the typical patient to present to the center at least three times per week for their hemodialysis treatments while peritoneal dialysis, as a home-based therapy, generally requires a patient to visit their nurse and physician only once per month. "This alone represents at least a 12-fold higher monthly cost of transportation for many in-center hemodialysis patients."

"Medicare expenditure differences in favor of peritoneal dialysis compared to in-center hemodialysis are significant" and Dr. Guest states may have been attenuated due to the fact that, in the United States, it appears that peritoneal dialysis patients are generally healthier overall than patients receiving in-center hemodialysis.
In the paper, it is mentioned that factors influencing the lesser use of PD include physician bias and lack of patient awareness due to insufficient exposure to full dialysis options education. Dr. Guest spoke of addressing the factors. "In testimony we recently submitted to the record for the House Ways and Means Committee, we provided recommendations to strengthen the education received by patients living with kidney disease who are Medicaid eligible. Medicaid accounts for one third of the starts on end stage kidney disease. As peritoneal dialysis patients rate greater satisfaction with this therapy compared to in-center hemodialysis, we point out the benefit of both increasing patient satisfaction and reducing overall Medicare costs as the Medicaid eligibles transition onto Medicare after 90 days".

In House testimony by colleague James Sloand, M.D., Medical Affairs U.S., Baxter Healthcare Dr. Sloand referenced that the lack of education about different modalities has been one of the significant reasons for underutilization in the U.S and surveys have shown that only 25% of patients on hemodialysis recall receiving information about the more cost-effective and cost-efficient peritoneal dialysis option. Dr. Sloand also commented that dialysis patients are a vulnerable and an underserved population that would benefit from improved influenza and bacterial pneumonia immunizations and greater vaccination rates could result in reduced risk of hospitalization and death from infections, which could further reduce Medicare expenditures