Safety-Net Care for Maintenance Dialysis in the United States
Authors: Kevin F. Erickson, Jenny I. Shen, Bo Zhao, Wolfgang C. Winkelmayer, Glenn M. Chertow, Vivian Ho, Jay Bhattacharya
Journal: Journal of the American Society of Nephrology (2019)

Significance Statement Information about where patients in the United States with limited health insurance coverage receive maintenance dialysis has been lacking. The authors identified patients who were “safety-net reliant”—those who were uninsured and who did not qualify for Medicare had only Medicaid coverage—and found the proportion of patients &lt;65 years initiating dialysis who were safety net–reliant increased between 2008 and 2015 from 11% to 14%. Although 73% of patients who were safety-net reliant received care at for-profit/chain-owned facilities, they were 30% more likely to start dialysis at nonprofit/independently owned (often hospital-affiliated) facilities compared with other facility ownership types—an association most pronounced among patients without insurance. Ongoing loss of market share of nonprofit/independently owned and hospital-based facilities may affect access to outpatient dialysis care for populations with limited health insurance coverage. Background Although most American patients with ESKD become eligible for Medicare by their fourth month of dialysis, some never do. Information about where patients with limited health insurance receive maintenance dialysis has been lacking. Methods We identified patients initiating maintenance dialysis (2008–2015) from the US Renal Data System, defining patients as “safety-net reliant” if they were uninsured or had only Medicaid coverage at dialysis onset and had not qualified for Medicare by the fourth dialysis month. We examined four dialysis facility ownership categories according to for-profit/nonprofit status and ownership (chain versus independent). We assessed whether patients who were safety-net reliant were more likely to initiate dialysis at certain facility types. We also examined hospital-based affiliation. Results The proportion of patients &lt;65 years initiating dialysis who were safety-net reliant increased significantly over time, from 11% to 14%; 73% of such patients started dialysis at for-profit/chain-owned facilities compared to 76% of all patients starting dialysis. Patients who were safety-net reliant had a 30% higher relative risk of initiating dialysis at nonprofit/independently owned versus for-profit/independently owned facilities (odds ratio, 1.30; 95% CI, 1.24 to 1.36); they had slightly lower relative risks of initiating dialysis at for-profit and non-profit chain-owned facilities, and were more likely to receive dialysis at hospital-based facilities. These findings primarily reflect increased likelihood of dialysis among patients without insurance at certain facility types. Conclusions Although most patients who were safety-net reliant received care at for-profit/chain-owned facilities, they were disproportionately cared for at nonprofit/independently owned and hospital-based facilities. Ongoing loss of market share of nonprofit/independently owned outpatient dialysis facilities may affect safety net–reliant populations.