Medicare and end-stage renal disease (ESRD)
The Medicare ESRD program is designed to assure qualifying beneficiaries access to high quality, cost-effective medical care. To a large extent, it has succeeded. Today, over 90 percent of all patients being treated for ESRD ultimately receive some Medicare reimbursement.
This report discusses the growth in the number of participating renal facilities furnishing some form of ESRD treatment. (See glossary for definition of terms.)
Growth in numbers and types of facilities (Figure 1)
Figure 1. Medicare, number of end-stage renal disease facilities, hospital-based versus free-standing: selected years.
Since the ESRD program began in 1973, the total number of renal facilities has more than doubled to 1,309 in 1983. From 1982 to 1983 alone, there were 7.5 percent more participating ESRD facilities.
The growth in the number of renal facilities has been primarily among freestanding units, i.e., units not affiliated with hospitals. In 1973, freestanding units represented about one out of nine renal facilities (11.2 percent); hospital units or hospital satellites made up the remaining eight out of nine (88.8 percent). By 1983, almost one out of every two renal facilities (47.9 percent) was freestanding.
Ownership or control (Table 1)
Table 1. Number of certified end-stage renal disease providers or facilities, by type of ownership and type of facility: 1980-83.
| 1980 | 1981 | 1982 | 1983 | |||||
|---|---|---|---|---|---|---|---|---|
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| Number | Percent | Number | Percent | Number | Percent | Number | Percent | |
| All facilities | 1,073 | 100.0 | 1,162 | 100.0 | 1,218 | 100.0 | 1,309 | 100.0 |
| Proprietary | 323 | 30.1 | 408 | 35.1 | 437 | 35.9 | 504 | 38.5 |
| Hospital based | 23 | 2.1 | 21 | 1.8 | 14 | 1.1 | 14 | 1.1 |
| Hospitals | 23 | 2.1 | 21 | 1.8 | 14 | 1.1 | 14 | 1.1 |
| Hospital satellites | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 |
| Freestanding | 300 | 28.0 | 387 | 33.3 | 423 | 34.7 | 490 | 37.4 |
| Nonprofit | 750 | 69.9 | 754 | 64.9 | 781 | 64.1 | 805 | 61.5 |
| Hospital based | 620 | 57.8 | 655 | 56.4 | 677 | 55.6 | 668 | 51.0 |
| Hospitals | 593 | 55.3 | 625 | 53.8 | 643 | 52.8 | 638 | 48.7 |
| Hospital satellites | 27 | 2.5 | 30 | 2.6 | 34 | 2.8 | 30 | 2.3 |
| Freestanding | 130 | 12.1 | 99 | 8.5 | 104 | 8.5 | 137 | 10.5 |
In 1983, almost four out of every ten (38.5 percent) renal facilities were proprietary and were almost exclusively freestanding. Proprietary facilities represent an increasing proportion of all facilities.
Nonprofit renal facilities, on the other hand, are mainly hospital based (that is, either hospital units or hospital satellites).
Type of renal care provided (Table 2)
Table 2. Number of certified end-stage renal disease facilities and centers, by type of facility or center, type of service, and Health Care Financing Administration (HCFA) administrative region: December 1983.
| HCFA administrative region | Total facilities and centers1 (1) |
Transplant | Dialysis | Approved dialysis stations | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
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| All hospital transplant centers2 (2) |
Hospital transplant only centers (3) |
Hospital dialysis and transplant centers (4) |
All suppliers3 (5) |
Inpatient hospital care (6) |
Primarily outpatient | Number (12) |
Per 1,000 enrollees | ||||||
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| Total facilities and centers4 (7) |
Hospital dialysis only center (8) |
Hospital dialysis facilities (9) |
Hospital dialysis and transplant centers (10) |
Nonhospital dialysis facilities (11) |
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| All regions | 1,309 | 159 | 13 | 146 | 1,296 | 49 | 1,247 | 363 | 111 | 146 | 627 | 15,511 | 181 |
| Boston | 53 | 11 | 0 | 11 | 53 | 0 | 53 | 26 | 2 | 11 | 14 | 602 | 132 |
| New York | 130 | 18 | 2 | 16 | 128 | 0 | 128 | 79 | 5 | 16 | 28 | 1,476 | 127 |
| Philadelphia | 176 | 20 | 0 | 20 | 176 | 7 | 169 | 49 | 7 | 20 | 93 | 2,091 | 214 |
| Atlanta | 257 | 21 | 1 | 20 | 256 | 11 | 245 | 21 | 12 | 20 | 192 | 3,428 | 210 |
| Chicago | 202 | 33 | 1 | 32 | 201 | 11 | 190 | 76 | 30 | 32 | 52 | 2,499 | 165 |
| Dallas | 176 | 20 | 3 | 17 | 173 | 5 | 168 | 35 | 16 | 17 | 100 | 2,018 | 218 |
| Kansas City | 52 | 10 | 1 | 9 | 51 | 0 | 51 | 14 | 13 | 9 | 15 | 569 | 155 |
| Denver | 45 | 3 | 0 | 3 | 45 | 4 | 41 | 11 | 8 | 3 | 19 | 400 | 225 |
| San Francisco | 189 | 18 | 2 | 16 | 187 | 10 | 177 | 43 | 18 | 16 | 100 | 2,194 | 188 |
| Seattle | 29 | 5 | 3 | 2 | 26 | 1 | 25 | 9 | 0 | 2 | 14 | 234 | 110 |
Unduplicated count of all certified ESRD facilities and centers = (3) + (4) + (6) + (7) + (8) + (9) + (11); column (10) is not counted again as it is a repeat of column (4).
All hospital transplant centers = (3) + (4).
All dialysis suppliers = (6) + (7).
Total facilities and centers primarily providing outpatient dialysis = (8) + (9) + (10) + (11).
Total dialysis facilities (including hospital and freestanding) = (9) + (11).
NOTES:
Total hospital based facilities and centers (including transplant, inpatient dialysis and outpatient dialysis) = (3) + (4) + (6) + (8) + (9); column (10) is not counted again as it is a repeat of column (4).
In 1983, just over 6,000 renal transplants were performed in 155 renal hospital units called “transplant centers.” (A total of 159 units were actually approved to perform transplants.) All but 13 of these transplant centers also provide outpatient dialysis services.
Patients not receiving kidney transplants receive dialysis care either at home or at one of the 1,296 renal facilities providing at least one dialysis service. The overwhelming majority (1,247) of these facilities provide care in a predominantly outpatient setting. Of this number, 738 are “dialysis facilities,” which means they are approved to furnish at least one dialysis service. These facilities may be in either a hospital (111) or nonhospital (627) setting.
Another 509 locations are called “dialysis centers” as opposed to dialysis facilities. These are hospital units which, in addition to providing dialysis service(s), are also approved to furnish the full spectrum of diagnostic, therapeutic, and rehabilitative services. Of the total number of dialysis centers, 146 are also transplant centers.
Finally, 49 renal dialysis centers are defined as “inpatient care” centers because they provide backup dialysis services only, and 20 percent or less of their dialysis is performed on an outpatient basis.
Regional comparisons—dialysis facilities and populations
There is over a threefold variation in the proportion of all facilities that are freestanding, from a low of 22 percent in New York to a high of 75 percent in Atlanta.
Most of the services and supplies needed by people with permanent kidney failure are covered only by supplementary medical insurance (SMI)—e.g., outpatient maintenance dialysis, self-dialysis training, and home dialysis. While the number of ESRD SMI enrollees varies considerably by region (Figure 2), ESRD enrollees as a percent of total enrollees is relatively constant across regions (Figure 3).
The number of dialysis stations per 1,000 ESRD SMI enrollees varies significantly by region, from a low of 110 in Seattle to a high of 225 in Denver; however, those regions such as Seattle with low outpatient dialysis stations may have a high home dialysis population.
Figure 2. Medicare: Number of supplementary medical insurance end-stage renal disease enrollees, by region: July 1983.
Figure 3. Medicare: End-stage renal disease as a percent of total supplementary medical insurance enrollees, by region: July 1983.
Glossary of terms
- Dialysis
A process of maintaining the chemical balance of the blood when the kidneys have failed; specifically, a process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane. The types of dialysis currently used are hemodialysis, peritoneal dialysis, continuous ambulatory peritoneal dialysis, and continuous cycling peritoneal dialysis.
- Dialysis station
The treatment area which is designed and equipped to provide adequate and safe dialysis therapy, as well as privacy and comfort for patients.
- Dialysis center
A hospital unit approved to furnish the full spectrum of diagnostic, therapeutic (including patient dialysis furnished directly or under arrangement) and rehabilitative services, except renal transplantation, for the care of ESRD dialysis patients.
- Dialysis facility
A unit (hospital based or freestanding) which is approved to furnish dialysis service(s) to ESRD patients.
- End-stage renal disease (ESRD)
That stage of renal impairment which is irreversible and permanent and requires dialysis or kidney transplantation to ameliorate uremic symptoms and maintain life.
- ESRD facility
A supplier of health care services that is approved to furnish at least one specific ESRD service.
- Hemodialysis
A method of dialysis in which blood from a patient's body is circulated through an external device or machine and thence returned to the patient's bloodstream. Such an artificial kidney machine usually is designed to remove fluids and metabolic end products from the bloodstream by placing the blood in contact with a semi-permeable membrane which is bathed on the other side by an appropriate chemical solution referred to as dialysate.
- Inpatient Care Only
A renal dialysis center which performs backup services for dialysis facilities and performs 20 percent or less of their dialysis on an outpatient basis.
- Inpatient dialysis
Dialysis which, because of medical necessity, is furnished to an ESRD patient on a temporary inpatient basis in a hospital.
- Transplant
The surgical procedure that involves excising an organ from either a cadaver or from a living donor and implanting it in the patient.
- Transplant center
A hospital unit which is approved to furnish direct transplantation and other medical and surgical specialty services for the care of ESRD transplant patients including inpatient dialysis furnished directly or under arrangement.