Baerman EA, et al. J Am Soc Nephrol. 2022;doi: 10.1681/ASN.2021060854.
Baerman EA, et al. J Am Soc Nephrol. 2022;doi: 10.1681/ASN.2021060854.
Barriers to widespread peritoneal dialysis use in the United States include misaligned incentives, varying data, temporary transitioning costs and more, according to a review published in the Journal of the American Society of Nephrology.
“The [HHS] 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,” Elliot A. Baerman, from the section of nephrology at Baylor College of Medicine in Texas, and colleagues wrote. They added, “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.”
According to the review, most analyses comparing costs of PD focus on the health care payer’s perspective rather than those making health care decisions. These analyses lack information about how cost differences can impact treatment choices.
“Analyses conducted from the payer’s perspective lack critical information about who benefits from potential savings,” Baerman and colleagues wrote. They added, “Similar to expansion of the ESRD Prospective Payment System, policies to promote PD will be most effective if they pass a meaningful portion of cost savings from payers to the patients, caregivers, physicians, and dialysis facilities who make decisions about treatment modality.”
Researchers noted that more data are needed to understand the costs of PD among patients and caregivers. While PD may give patients more flexibility, it may require them to give up time, physical space and cause stress to administer dialysis at home. These perceived costs could deter patients from choosing PD, especially among those in a socioeconomically disadvantaged situation.
Similarly, physicians may sacrifice considerable time when preparing patients for PD which keeps them from their “revenue-generating activities.” Although there are incentives for educating patients about their disease, more policies that reimburse physicians for additional costs linked with PD may help increase the use of PD.
Baerman and colleagues referenced an analysis of a cost report that revealed instructions on how to allocate labor and capital costs across modalities may be outdated. They suggested that without reliable data, the cost of PD in the United States may vary. Therefore, reliable and valid data about differences in cost between dialysis modalities could help better reimbursement models. Another potential barrier to widespread PD is transitioning cost.
“Even if the average cost of PD measured across one or more dialysis providers is less than the average cost of in-center hemodialysis and revenues are equal, it may still be economically advantageous for many facilities to continue providing more in-center hemodialysis,” Baerman and colleagues wrote. “One way that this might occur is if the cost of PD relative to in-center hemodialysis is substantially higher for the new patients who would be started on PD.”
Baerman and colleagues suggest that policy solutions must include incentives that address the costs to patients, caregivers and physicians. Additionally, organizations such as hospitals and skilled nursing facilities should be included in new pay models and policies so that transitioning costs are not a deterrent to PD.
“We identified several cost considerations that limit the use of PD, including misaligned economic incentives, costs incurred by the people making decisions about dialysis modality, variation in costs across dialysis providers and temporary costs incurred during the transition to increased use of PD,” Baerman and colleagues wrote. “Improved data collection, combined with policies that address these limitations through shared savings, will be necessary to achieve the ambitious goals set forth in the [Advancing American Kidney Health initiative] AAKHI.”
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