Can changes in Medicare payments reduce potential disparities in peritoneal dialysis?

Recent policy changes have affected the way that Medicare pays for dialysis, with the goal of improving the overall quality and efficiency of care. As with any new health care payment model, there is a need to determine whether these changes affect health disparities. Does the new model inadvertently lead to worse outcomes for some patients, or does it create new incentives for providers to help overcome barriers to care? In a paper published in Health Services Research, investigators evaluated the effect of these recent Medicare changes on potential disparities in the use of one type of dialysis: peritoneal dialysis.

People diagnosed with end-stage renal disease (ESRD) may choose between two primary types of dialysis: hemodialysis and peritoneal dialysis (PD). Hemodialysis is the most common treatment and is typically performed in a dialysis facility three times per week for three to four hours per treatment. The major alternative dialysis therapy, PD, relies on a peritoneal catheter and is generally a home-based therapy.

Until recently, there was a longstanding decline in the use of PD in the US. In 1983, 15 percent of incident dialysis patients selected PD, but this number declined to only 6 percent in 2008. In 2011, Medicare implemented a new prospective payment system that established the same payment rates for hemodialysis and PD with the intent of encouraging the use of PD.

Under this new system, there has been growth in PD among diverse subgroups of patients, with 9.3 percent of incident patients selecting PD in 2013. However, the differences in PD selection across patient subgroups that existed before the reform have largely remained the same in the first few years after the reform. Both before and after the implementation of the new payment system, researchers found that lower selection of PD was associated with:

• older age
• black race
• Hispanic ethnicity
• less pre-ESRD care
• Medicaid insurance

Lead author Dr. Marc Turenne commented, “We learned in this study that despite strong new financial incentives favoring use of a home-based therapy, which is likely to have advantages for some patients, it continues to be used less frequently among several patient groups who have historically faced greater health disparities.”

These results suggest that even with additional changes in financial incentives, there may be ongoing disparities in care that will require more targeted efforts.