Payment for Dialysis Services in the Individual Market

Abstract

This cross-sectional study examines the prevalence and spending of patients with end-stage kidney disease in the individual market.

Although 80% of US patients who receive dialysis for end-stage kidney disease (ESKD) have Medicare as their primary payer, recent evidence suggests an increasing share with other coverage.¹ Some policy makers allege that dialysis facilities encourage individual market enrollment by subsidizing individual market premiums through contributions to patient assistance foundations.² This strategy could increase profits for facilities because commercial plans pay more for dialysis than Medicare,³ but could also increase individual market spending if patients receiving dialysis have above-average spending.

To our knowledge, little is known about the prevalence and spending of patients with ESKD in the individual market. Prior commercial market studies were limited to financial records of 1 chain, combined employer and individual plans, and only examined dialysis spending.³ To address these gaps, we used claims data for individual market plans and analyzed dialysis and nondialysis spending.

Methods

Using 2016 US Affordable Care Act–compliant individual market claims data held by a health care analytics firm, we estimated the prevalence of patients with ESKD and average monthly spending on dialysis services and all services. The data encompass 50 million member months, comprising 28% of 2016 Affordable Care Act–compliant enrollment. We computed average monthly spending by dividing the total allowed amounts, including cost-sharing, by member months. The University of Southern California institutional review board determined that the study met the criteria for coded private information or biological specimens and thus was exempt from informed consent requirements.

We defined patients with ESKD as those who were assigned an ESKD hierarchical condition category code who received at least 1 outpatient dialysis service in 2016. Hierarchical condition category codes are derived from diagnosis codes and used to risk-adjust health plan payments.

We used these estimates to calculate the expected increase in individual market spending if some nonaged Medicare enrollees with ESKD instead had individual market coverage. To compare individual market dialysis spending with Medicare, we used claims from a 100% sample of traditional Medicare patients with ESKD. The eAppendix in the Supplement provides additional detail.

Results

Patients with ESKD comprised 0.10% of individual market member months (51 002 of 50 million) but 3.3% of spending ($734 million of $21 billion). Their average monthly spending on all services was $14 399, 33 times the spending by enrollees without ESKD ($435) (Table 1).

Table 1. Average Monthly Spending for Patients Without and With ESKD by Market Segment, 2016.

Patients	Enrollment months
	All months	Months with a dialysis service
	Individual market	Individual market	Medicare	Individual market as a percentage of Medicare
Without ESKD, $	435	NA	NA	NA
With ESKD, $
Outpatient dialysis	8622	10 149	3364	302
All services	14 399	NA	NA	NA

Abbreviation: ESKD, end-stage kidney disease; NA, not applicable.

Individual market enrollees with ESKD received 1 or more outpatient dialysis services in 85% of enrolled months. For months with at least 1 dialysis service, the average monthly outpatient dialysis spending was $10 149, or 302% of the corresponding estimate for Medicare ($3364). Shifting 10% of nonaged Medicare enrollees with ESKD who were receiving dialysis into the individual market would increase individual market ESKD prevalence to 0.24% and overall average spending by 4.1% (Table 2).

Table 2. Prevalence and Spending Effect of Shifting Nonaged Medicare Beneficiaries With ESKD to the Individual Market, 2016.

Percentage of nonaged Medicare beneficiaries with ESKD receiving dialysis shifting from traditional Medicare to individual market	%
	Individual market ESKD prevalence	Change in average individual market claims spending
0 (Status quo)	0.10	NA
10	0.24	+4.1
20	0.37	+8.2
40	0.63	+16.4

Abbreviations: ESKD, end-stage kidney disease; NA, not applicable.

Discussion

Individual market plans paid approximately 3 times what Medicare paid for dialysis services, underscoring the incentive for facilities to encourage individual market enrollment. Steering Medicare beneficiaries into the individual market would raise premiums, which would increase spending by enrollees without federal premium subsidies. Additionally, higher federal spending on premium subsidies would likely exceed the offsetting Medicare savings.

Policy makers have options to discourage steering. Although a federal judge blocked a 2016 federal rule that directly limited third-party assistance, citing procedural problems,⁴ the rule could be reissued or Congress could enact similar restrictions.⁵ Similarly, California enacted legislation in 2019 that capped dialysis reimbursement at Medicare rates for patients who were receiving third-party assistance. An ongoing lawsuit alleges that California’s law violates federal law, but even if it succeeds, Congress could implement similar restrictions nationally.⁶

A limitation of our study is that we estimated the average spending for all patients with ESKD in the individual market and Medicare, who might not represent patients who are targeted by the steering efforts of facilities. Additionally, our individual market data might not represent the entire market.

We also could not examine how transitions to the individual market might affect patient cost-sharing and networks. Those effects depend on whether the patient had Medicare Advantage or Medicare supplemental coverage, the specific individual market plan selected, and whether patients receive other cost-sharing assistance.

Supplement.

eAppendix. Counterfactual calculation