American Journal of Kidney Diseases

Financial Implications of Choice of Dialysis Type of the Revised Medicare Payment System: An Economic Analysis


      In 2011, the Medicare Improvements for Patients and Providers Act replaced the case-mix–adjusted composite payment system for Medicare outpatient dialysis facilities with a bundled end-stage renal disease prospective payment system (PPS). We assessed the economic implications for modality choice of the revised Medicare payment system.

      Study Design

      Microeconomic analyses.

      Setting & Population

      Patients eligible for dialysis in the United States.

      Model, Perspective, & Timeframe

      The perspective of this analysis is that of a financial administrator of a representative dialysis center in the United States. Data were obtained from the Medicare Payment Advisory Commission, the US Renal Data System, the DOPPS (Dialysis Outcomes and Practice Patterns Study) Practice Monitor, the US Bureau of Labor Statistics, and Medicare fee schedules.


      Recently implemented end-stage renal disease PPS versus the prior case-mix composite payment system.


      Medicare payment per month, center fixed and variable costs per month, net difference in revenue and variable costs (direct contribution), and net difference in revenue and total costs (operating margin).


      The direct contribution and operating margin for in-center hemodialysis and peritoneal dialysis are expected to be positive under the new bundled PPS. For Medicare fiscal intermediaries/administrators, paid treatments for home hemodialysis vary from 3.2 to more than 4.8 per week. The direct contribution and operating margin are expected to be negative for home hemodialysis if the number of paid treatments is similar between in-center and home hemodialysis; they are almost identical when the number of paid treatments increases for home hemodialysis by approximately 1 per week.


      Experience across centers and intermediaries/administrators may vary. Sensitivity analyses were conducted to assess the robustness of findings and determine which variables most influenced results.


      The new bundled PPS created a financial incentive for increased use of peritoneal dialysis. Use of home hemodialysis may be influenced by number of paid treatments per week.

      Index Words

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        • US Renal Data System
        USRDS 2011 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States.
        Am J Kidney Dis. 2012; 59 (suppl 1): e1-e420
        • Nissenson A.R.
        • Prichard S.S.
        • Cheng I.K.
        • et al.
        ESRD modality selection into the 21st century: the importance of non medical factors.
        ASAIO J. 1997; 43: 143-150
        • Dor A.
        • Pauly M.V.
        • Eichleay M.A.
        • Held P.J.
        End-stage renal disease and economic incentives: the International Study of Health Care Organization and Financing (ISHCOF).
        Int J Health Care Finance Econ. 2007; 7: 73-111
        • Romeo A.
        Health Technology Case Study 32: The Hemodialysis Equipment and Disposable Industry.
        Congressional Office of Technology Assessment, Washington, DC1984
        • Stason W.
        • Barnes B.
        The Effectiveness and Costs of Continuous Ambulatory Peritoneal Dialysis (CAPD).
        Congressional Office of Technology Assessment, Washington, DCSeptember 1985
        • Wang V.
        • Lee S.Y.
        • Patel U.D.
        • Maciejewski M.L.
        • Ricketts T.C.
        Longitudinal analysis of market factors associated with provision of peritoneal dialysis services.
        Med Care Res Rev. 2011; 68: 537-558
        • Wang V.
        • Lee S.Y.
        • Patel U.D.
        • Weiner B.J.
        • Ricketts T.C.
        • Weinberger M.
        Geographic and temporal trends in peritoneal dialysis services in the United States between 1995 and 2003.
        Am J Kidney Dis. 2010; 55: 1079-1087
        • Golper T.A.
        • Saxena A.B.
        • Piraino B.
        • et al.
        Systematic barriers to the effective delivery of home dialysis in the United States: a report from the Public Policy/Advocacy Committee of the North American Chapter of the International Society for Peritoneal Dialysis.
        Am J Kidney Dis. 2011; 58: 879-885
        • Medicare Payment Advisory Commission
        Report to the Congress: Medicare Payment Policy.
        Medicare Coverage Advisory Commission, Washington, DC2006
        • Medicare Payment Advisory Commission
        Report to the Congress: Medicare Payment Policy.
        Medicare Coverage Advisory Commission, Washington, DC2011
        • Mehrotra R.
        • Marsh D.
        • Vonesh E.
        • et al.
        Patient education and access of ESRD patients to renal replacement therapies beyond in-center hemodialysis.
        Kidney Int. 2005; 68: 378-390
      1. End Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Consolidated Billing for Limited Part B Services.
        (MLN Matters® no. MM7064 Revised) Centers for Medicare & Medicaid Services (CMS), Baltimore, MD2011
      2. 42 CFR Parts 410, 413 and 414 Medicare Program; End-Stage Renal Disease Prospective Payment System, Final Rule, in Centers for Medicare & Medicaid Services (CMS) and Department of Health and Human Services.
        Fed Regist. 2010; 75: 49030-49211
        • Chertow G.M.
        • Levin N.W.
        • Beck G.J.
        • et al.
        In-center hemodialysis six times per week versus three times per week.
        N Engl J Med. 2010; 363: 2287-2300
      3. Facility Survey Public Use Files.
        Centers for Medicare & Medicaid Services (CMS), Baltimore, MD2004
      4. Medicare Part B Drug Average Sales Price.
        Manufacturer Reporting of Average Sales Price (ASP) Data. Centers for Medicare & Medicaid Services, Baltimore, MD2011
      5. Dialysis Outcomes and Practice Patterns (DOPPS) Practice Monitor.
        Arbor Research Collaborative for Health, Ann Arbor, MI2011
        • Bureau of Labor Statistics
        Occupational Outlook Handbook, 2008-09 ed..
        US Department of Labor, Washington, DC2011
      6. ESRD PC Pricer.
        Centers for Medicaid and Medicare Services (CMS), Department of Health and Human Services, Ann Arbor, MI2011
        • Hirth R.
        • Sleeman K.
        • Wheeler J.
        • et al.
        Frequency of payments for more than thrice weekly dialysis for home hemodialysis (HHD). In: Proceedings of the American Society of Nephrology Kidney Week, November 10.
        San Diego, CA. Abstract SA-PO297. 2011;
        • Consolidated Renal Operations in a Web Enabled Network (CROWNWeb)
        (Accessed January 15, 2012)
        • Vachharajani T.J.
        Hemodialysis vascular access care in the United States: closing gaps in the education of patient care technicians.
        Semin Dial. 2011; 24: 92-96
        • Davies S.
        Module 3b: peritoneal dialysis.
        Clinical Practice Guidelines. UK Renal Association, Hampshire, UK2006
        • Russo R.
        • Manili L.
        • Tiraboschi G.
        • et al.
        Patient re-training in peritoneal dialysis: why and when it is needed.
        Kidney Int Suppl. 2006; 70: S127-S132
        • Lacson Jr, E.
        • Lazarus J.M.
        Dialyzer best practice: single use or reuse?.
        Semin Dial. 2006; 19: 120-128
        • Upadhyay A.
        • Sosa M.A.
        • Jaber B.L.
        Single-use versus reusable dialyzers: the known unknowns.
        Clin J Am Soc Nephrol. 2007; 2: 1079-1086
        • Winkelmayer W.C.
        Potential effects of the new Medicare prospective payment system on drug prescription in end-stage renal disease care.
        Blood Purif. 2011; 31: 66-69
        • Wolfe W.A.
        Adequacy of dialysis clinic staffing and quality of care: a review of evidence and areas of needed research.
        Am J Kidney Dis. 2011; 58: 166-176
        • Culleton B.F.
        • Walsh M.
        • Klarenbach S.W.
        • et al.
        Effect of frequent nocturnal hemodialysis vs conventional hemodialysis on left ventricular mass and quality of life: a randomized controlled trial.
        JAMA. 2007; 298: 1291-1299
        • Rocco M.V.
        • Larive B.
        • Eggers P.W.
        • et al.
        Baseline characteristics of participants in the Frequent Hemodialysis Network (FHN) daily and nocturnal trials.
        Am J Kidney Dis. 2011; 57: 90-100
        • Quinn R.R.
        • Hux J.E.
        • Oliver M.J.
        • Austin P.C.
        • Tonelli M.
        • Laupacis A.
        Selection bias explains apparent differential mortality between dialysis modalities.
        J Am Soc Nephrol. 2011; 22: 1534-1542
        • Leavitt M.O.
        Report to Congress: A Design for a Bundled End Stage Renal Disease Prospective Payment System.
        2008 (Washington, DC)
        • Feldman R.L.
        • Ple-Plakon A.
        • Desmarais M.
        Analysis of Medicare Cost Reports Reveals Inaccurate Modality Costs.
        The Moran Group, Washington, DC2008
        • US Food and Drug Administration. March 2007 EPOGEN® US product insert, including CHOIR and AOC updates
        (2007Accessed January 15, 2012)
        • DeOreo P.B.
        Finances of the independent dialysis facility.
        Blood Purif. 2007; 25: 7-11
        • DeOreo P.B.
        How dialysis is paid for: what the dialysis medical director should know, and why.
        Semin Dial. 2008; 21: 58-62
        • Goeree R.
        • Manalich J.
        • Grootendorst P.
        • Beecroft M.L.
        • Churchill D.N.
        Cost analysis of dialysis treatments for end-stage renal disease (ESRD).
        Clin Invest Med. 1995; 18: 455-464
        • Kroeker A.
        • Clark W.F.
        • Heidenheim A.P.
        • et al.
        An operating cost comparison between conventional and home quotidian hemodialysis.
        Am J Kidney Dis. 2003; 42: 49-55
        • Kroeker A.D.
        • McFarlane P.
        • Mohr P.
        A business model approach to quotidian hemodialysis.
        Contrib Nephrol. 2004; 145: 106-116
        • McFarlane P.A.
        • Bayoumi A.M.
        • Pierratos A.
        • et al.
        The quality of life and cost utility of home nocturnal and conventional in-center hemodialysis.
        Kidney Int. 2003; 64: 1004-1011
        • McFarlane P.A.
        • Pierratos A.
        • Redelmeier D.A.
        Cost savings of home nocturnal versus conventional in-center hemodialysis.
        Kidney Int. 2002; 62: 2216-2222
        • Mohr P.E.
        The economics of daily dialysis.
        Adv Ren Replace Ther. 2001; 8: 273-279
        • Mohr P.E.
        • Neumann P.J.
        • Franco S.J.
        • Marainen J.
        • Lockridge R.
        • Ting G.
        The case for daily dialysis: its impact on costs and quality of life.
        Am J Kidney Dis. 2001; 37: 777-789
        • Robers S.
        Cost of daily hemodialysis.
        ASAIO J. 2001; 47: 459-461
        • Robers S.
        • Lowrie E.G.
        Quantitative methods for estimating the future need for and optimum location of ESRD service facilities.
        Proc Clin Dial Transplant Forum. 1978; 8: 9-19