Cost Barriers to More Widespread Use of Peritoneal Dialysis in the United States

Abstract

The United States Department of Health and Human Services launched the Advancing American Kidney Health Initiative in 2019, which included a goal of transforming dialysis care from an in-center to a largely home-based dialysis program. A substantial motivator for this transition is the potential to reduce costs of ESKD care with peritoneal dialysis. Studies demonstrating that peritoneal dialysis is less costly than in-center hemodialysis have often focused on the perspective of the payer, whereas less consideration has been given to the costs of those who are more directly involved in treatment decision making, including patients, caregivers, physicians, and dialysis facilities. We review comparisons of peritoneal dialysis and in-center hemodialysis costs, focusing on costs incurred by the people and organizations making decisions about dialysis modality, to highlight the financial barriers toward increased adoption of peritoneal dialysis. We specifically address misaligned economic incentives, underappreciated costs for key stakeholders involved in peritoneal dialysis delivery, differences in provider costs, and transition costs. We conclude by offering policy suggestions that include improving data collection to better understand costs in peritoneal dialysis, and sharing potential savings among all stakeholders, to incentivize a transition to peritoneal dialysis.

Keywords: ESKD; United States; chronic dialysis; economic analysis; peritoneal dialysis.

Figure 1.

Estimated cost savings from more widespread use of PD that could be shared between Medicare and other key decision makers. The chart divides 100% of Medicare Parts AB expenditures in the expanded End-Stage Renal Disease Prospective Payment System into categories. Using total in-center hemodialysis (ICHD) costs as a baseline, dialysis and nondialysis costs were apportioned from data published in the United States Renal Data System (USRDS) Annual Data Report (ADR). We assumed that nondialysis costs and injectable medication costs vary by modality. The ratio of non-dialysis costs in PD versus ICHD (0.78) was derived from USRDS ADR data. The proportion of total dialysis costs accounted for by injectable medications (0.28) and the ratio of injectable medication costs in PD versus ICHD were obtained from a study of Medicare cost reports. HD, hemodialysis.

Figure 2.

Opportunities to transfer potential savings from payers to patients, caregivers, physicians, and dialysis facilities to address additional costs associated with the use of PD. Potential savings to payers from more use of PD could be used to offset costs to patients and caregivers, physicians, and dialysis facilities.