Health Policy for Dialysis Care in Canada and the United States

Abstract

Contemporary dialysis treatment for chronic kidney failure is complex, is associated with poor clinical outcomes, and leads to high health costs, all of which pose substantial policy challenges. Despite similar policy goals and universal access for their kidney failure programs, the United States and Canada have taken very different approaches to dealing with these challenges. While US dialysis care is primarily government funded and delivered predominantly by private for-profit providers, Canadian dialysis care is also government funded but delivered almost exclusively in public facilities. Differences also exist for regulatory mechanisms and the policy incentives that may influence the behavior of providers and facilities. These differences in health policy are associated with significant variation in clinical outcomes: mortality among patients on dialysis is consistently lower in Canada than in the United States, although the gap has narrowed in recent years. The observed heterogeneity in policy and outcomes offers important potential opportunities for each health system to learn from the other. This article compares and contrasts transnational dialysis-related health policies, focusing on key levers including payment, finance, regulation, and organization. We also describe how policy levers can incentivize favorable practice patterns to support high-quality/high-value, person-centered care and to catalyze the emergence of transformative technologies for alternative kidney replacement strategies.

Keywords: Chronic; Government; Health Care Costs; Kidney Failure; Renal Insufficiency; dialysis; health policy; innovation; peritoneal dialysis; transnational comparisons.

Figure 1.

Selected characteristics related to dialysis treatment (all modalities) for Canada and the United States. Sources: (A) the United States Renal Data System (USRDS) (70). (B) The USRDS (70) and the Canadian Organ Replacement Register (CORR) (23). (A) Comparison of the prevalence of dialysis treatment in Canada and the United States per million population. It shows that the prevalence of ESKD has been consistently higher over time in the United States (P<0.001), with a slight widening of this difference in recent years. (B) Comparison of eGFR at initiation of dialysis in Canada versus the United States. It shows fluctuations in both countries over time, with eGFR at dialysis progressively increasing from 2005 to 2010 and then decreasing thereafter. eGFR at initiation of dialysis has been slightly higher in Canada than in the United States (P<0.001).

Figure 2.

Survival after initiation of dialysis (all modalities) differ for Canada and the United States. Sources: the USRDS (70) and the CORR (23). The figure compares unadjusted survival at various time points (3 months and 1, 3, and 5 years) after initiation of dialysis among patients treated in Canada versus the United States. The figure shows that mortality at 1, 3, and 5 years is consistently lower in Canada than in the United States (for 1 and 3 years; all P<0.001) but that these between-country differences have tended to narrow over time. For survival at 3 months, mortality was lower in the United States than in Canada during 2014–2016 (P<0.001), although the magnitude of the difference was very small.

Figure 3.

Timeline of the regulatory landscape changes for ESKD in the United States, 2008–2016. The figure shows key changes in the regulatory landscape for ESKD in the United States since 2008. The Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 established the current expanded prospective payment system (PPS) for reimbursement for the care of patients with ESKD in the United States. There have been no substantive changes in the regulatory landscape for ESKD in Canada over this period. CMS, Centers for Medicare and Medicaid Services; ESCO, ESRD Seamless Care Organizations; HHS, US Department of Health and Human Services; MAT, Measure Assessment Tool; QIP, Quality Incentive Program. Image credit: Matt Rivara, M.D.