A Comparison of US Medicare Expenditures for Hemodialysis and Peritoneal Dialysis

Abstract

Background: Observations that peritoneal dialysis (PD) may be an effective, lower-cost alternative to hemodialysis for the treatment of ESKD have led to policies encouraging PD and subsequent increases in its use in the United States.

Methods: In a retrospective cohort analysis of Medicare beneficiaries who started dialysis between 2008 and 2015, we ascertained average annual expenditures (for up to 3 years after initiation of dialysis) for patients ≥67 years receiving in-center hemodialysis or PD. We also determined whether differences in Medicare expenditures across dialysis modalities persisted as more patients were placed on PD. We used propensity scores to match 8305 patients initiating PD with 8305 similar patients initiating hemodialysis.

Results: Overall average expenditures were US$108,656 (2017) for hemodialysis and US$91,716 for PD (proportionate difference, 1.11; 95% confidence interval [CI], 1.09 to 1.13). This difference did not change over time (P for time interaction term=0.14). Hemodialysis had higher estimated intravenous (iv) dialysis drug costs (1.69; 95% CI, 1.64 to 1.73), rehabilitation expenditures (1.35; 95% CI, 1.26 to 1.45), and other nondialysis expenditures (1.34; 95% CI, 1.30 to 1.37). Over time, initial differences in total dialysis expenditures disappeared and differences in iv dialysis drug utilization narrowed as nondialysis expenditures diverged. Estimated iv drug costs declined by US$2900 per patient-year in hemodialysis between 2008 and 2014 versus US$900 per patient-year in PD.

Conclusions: From the perspective of the Medicare program, savings associated with PD in patients ≥67 years have remained unchanged, despite rapid growth in the use of this dialysis modality. Total dialysis expenditures for the two modalities converged over time, whereas nondialysis expenditures diverged.

Keywords: Medicare; United States; clinical epidemiology; dialysis; economic analysis; health expenditures; peritoneal dialysis.

Graphical abstract

Figure 1.

Flow chart illustrates the selection of 8305 matched pairs. Patients receiving any PD in 60 days after the first service date were considered as a patient on PD. Patients only receiving hemodialysis (HD) in the 60 days after the first service date were considered as patients on hemodialysis. PS, propensity score.

Figure 2.

Ratio of annual Medicare payments between patients on hemodialysis (HD) and those on PD varies across payment category. Results from model adjusting for hemoglobin, album, BMI, and pre-ESKD Medicare payment. Models include patients starting dialysis through 2015. Findings were not sensitive to analyses where we used a complete case cohort, excluded variables with large numbers of missing values (serum hemoglobin, albumin, and BMI), and excluded imputed Medicare Part D expenditures. Iv, intravenous.

Figure 3.

Difference on annual total dialysis payments between patients on hemodialysis (HD) and those on PD disappears over time. Percentage difference is (HD−PD costs)/(PD costs). Results from model adjusting for hemoglobin, album, BMI, and pre-ESKD Medicare payment. To allow 3 years of follow-up in each cohort, analyses of payment trends over time included patients initiating dialysis through 2014.

Figure 4.

Difference on annual intravenous (iv) dialysis drug payments between patients on hemodialysis (HD) and those on PD narrow over time, while other dialysis payments remain less for patients receiving HD. Difference is HD minus PD costs. Results from model adjusting for hemoglobin, album, BMI, and pre-ESKD Medicare payment. To allow 3 years of follow-up in each cohort, analyses of payment trends over time included patients initiating dialysis through 2014.