Home Dialysis in the United States after the End-Stage Renal Disease Prospective Payment System

Introduction:
The end-stage renal disease (ESRD) program makes up 7.1% of Medicare spending, even though patients on dialysis only represent 1.2% of the Medicare population. Home dialysis (peritoneal dialysis and home hemodialysis) is touted as a way to help reduce the high cost of (ESRD) in the United States (US). The Prospective Payment System (PPS) for ESRD, implemented by the Centers for Medicare & Medicaid Services (CMS) in January, 2011, introduced two financial incentives to increase home dialysis use: (i) bundling of injectable medications into a single payment for treatment and (ii) paying for home dialysis training.

Methods:
Because the training add-on was implemented 2.5 years after the announcement of the PPS, we were able to evaluate the effects of each component of the PPS on home dialysis use by patients starting dialysis in the US. We studied patients starting dialysis from January 1, 2006 to August 31, 2013. Using multivariable logistic regression, we analyzed data on dialysis modality, insurance type, and comorbidities from the United States Renal Data System (USRDS). We first computed the average predicted probability of choosing home dialysis under the PPS as well as the counterfactual predicted probabilities that (i) the PPS had never taken effect and (ii) the PPS was implemented without the home dialysis training add-on. By taking the difference in predicted probabilities between the actual and counterfactual, we estimated the effect of the PPS and the home dialysis training add-on on home dialysis use. Finally, we compared the PPS’ effect on Medicare Parts A/B beneficiaries to patients with other types of insurance.

Results:
Based on recent trends in practice, we projected home dialysis use to decrease over time with an estimated 8.4% (95% CI: 7.4%, 9.3%) of patients opting for home dialysis by the end of the study period. The PPS was associated with a reversal of trajectory, with a 5.0% (CI: 4.0%, 6.0%) increase in home dialysis use to 13.4% (CI: 13.1%, 13.6%) by the end of the study period. Home dialysis use increased by 5.8% (CI: 4.3%, 6.9%) among Medicare beneficiaries and 4.1% (CI: 2.3%, 5.4%) among patients covered by other forms of health insurance. The difference in change between these groups was not statistically significant (1.8%, CI: -0.2%, 3.8%). Conversely, in both populations, the training add-on was not associated with a statistically significant increase in home dialysis use beyond the effect of the PPS bundling (fully implemented PPS: 13.4%, CI: 13.1, 13.6% versus PPS without the training add-on: 13.9%, CI: 13.0%, 14.7%).

Conclusions:
The PPS bundling, but not the training add-on, led to substantial increases in home dialysis. These increases were identical for both Medicare and non-Medicare patients. These spill-over effects suggest that major payment changes in Medicare can affect all patients with ESRD. Programs similar to the ESRD PPS could enhance value in health care delivery to patients with other disease states common among Medicare beneficiaries.