The Dialysis Safety Net: Who Cares for Those Without Medicare?
Authors: Rebecca Thorsness, Amal N. Trivedi
Journal: Journal of the American Society of Nephrology (2020)

Safety net providers are a critical but threatened component of the United States health care system. Although safety net providers include a heterogeneous mix of hospitals, clinics, and other community-based organizations, they share a common mission to deliver care regardless of patients’ ability to pay or type of insurance. Therefore, safety net providers disproportionately serve uninsured, Medicaid-covered, and other vulnerable populations. Because care for uninsured patients is often uncompensated and Medicaid’s payment rates are typically lower than those of commercial or Medicare insurance, safety net providers often face challenging financial situations. Despite this, many safety net systems have developed innovative strategies to address the complex health and social needs of the low-income populations that they serve.1 In this issue of JASN, Erickson et al.2 examine the safety net for patients with ESKD receiving maintenance dialysis. In 1973, the federal Medicare program extended coverage to the vast majority of patients with ESKD; however, those who do not meet Medicare’s legal residency and work history requirements cannot qualify for coverage. Using national data, the authors find that 12% of the nonelderly population initiated dialysis while uninsured or covered by Medicaid and did not gain Medicare coverage by their fourth month of dialysis. The proportion of these “safety net–reliant” patients increased significantly over time. Notably, after 4 months postinitiation, very few patients subsequently gained Medicare eligibility, suggesting that they were effectively locked out of Medicare coverage. Although most safety net–reliant patients initiate maintenance dialysis in for-profit chain facilities, similar to other patients on maintenance dialysis, they were more likely to receive care in nonprofit or hospital-affiliated facilities. Uninsured patients in particular were less likely to receive care at for-profit chain facilities, which make up a large and growing share of the dialysis market. A major strength of the study was the use of a choice model to identify the facilities geographically available to patients initiating maintenance dialysis; interestingly, 20% of patients had only one facility ownership type available to them. Nonprofit, independent dialysis facilities—which are often hospital based—care for a disproportionate share of safety net–reliant patients, but these facilities serve a shrinking fraction of the dialysis population. This concerning trend mirrors the broader health care safety net, with hospital closures, provider consolidation, and other payment and delivery system reform initiatives threatening safety net health systems.1 Furthermore, there is accumulating evidence that independent and nonprofit dialysis facilities provide higher-quality care as measured by kidney transplantation listing and receipt as well as mortality and hospitalization rates.3,4 Thus, the shrinking safety net for maintenance dialysis care may threaten both access to and quality of care for patients who rely on these facilities. These findings open three important avenues for further study. First, although this study characterized safety net reliance as uninsured or Medicaid patients who did not acquire Medicare by the fourth month of dialysis, the Medicare population is heterogeneous and includes some segments that may overlap with the safety net–reliant population described in this study. For instance, dual-eligible Medicare beneficiaries have more complex medical and social needs, higher spending, and worse outcomes, and they are more likely to receive care from safety net providers than the Medicare-only population.5 Under Medicare’s value-based payment models for dialysis facilities, providers that disproportionately care for dual-eligible patients may be financially penalized if social risk factors are not considered.6 Furthermore, some Medicare-insured patients on dialysis may lack private supplemental coverage, and without such coverage, Medicare’s benefit design imposes 20% coinsurance for outpatient services. It is plausible that there may be similar sorting of Medicare-covered patients who lack supplemental coverage across facilities, because patients unable to afford this level of cost sharing for dialysis may need to rely on safety net assistance. Second, the Affordable Care Act (ACA) may have important implications regarding safety net reliance for the dialysis population.7 In states that expanded their Medicaid programs under the ACA to low-income nonelderly adults, the share of incident ESKD patients initiating maintenance dialysis who were covered by Medicaid grew significantly, whereas the share of uninsured patients fell.8 Erickson et al.2 found the association between being uninsured at dialysis initiation and dialysis site stronger than that for Medicaid, suggesting that uninsured patients rely more heavily on the dialysis safety net than Medicaid-covered patients. The ACA also eliminated preexisting condition exclusions in the individual market, enabling patients with ESKD to purchase such policies, including patients who would have likely otherwise remained uninsured. Furthermore, insurance coverage is not static. This study characterized coverage type (or lack thereof) at dialysis initiation, but the data were unable to track changes in non-Medicare coverage after initiation. Understanding insurance coverage before and after dialysis initiation in the postreform era and the implications of the ACA on patient sorting would be a useful addition. Third, the dialysis safety net must include consideration of individuals with ESKD who rely on emergency-only dialysis because they lack access to maintenance dialysis. Although outpatient dialysis facilities are not legally required to provide care to uninsured patients, federal law requires emergency departments to stabilize all individuals regardless of ability to pay, including patients with ESKD and life-threatening conditions arising from lack of maintenance dialysis. Because patients on emergency-only dialysis are not generally included in the US Renal Data System (USRDS) data, there is relatively little national information on the size of this population or their outcomes. Access to scheduled maintenance dialysis is associated with significantly lower mortality, cost, and health care utilization compared with emergency-only dialysis.9 However, for patients with ESKD without access to maintenance dialysis, most of whom are undocumented immigrants, public hospitals providing emergency-only dialysis serve as the safety net in many states.10 Erickson et al.2 provide evidence that, despite the expansion of near-universal Medicare coverage to the ESKD population, there remains an important fraction of patients initiating maintenance dialysis who are excluded from Medicare coverage. The share of these safety net–reliant patients is expanding, and these patients are not distributed across dialysis facilities in the same manner as their Medicare-covered counterparts. Moving forward, it will be important to monitor the implications of the shrinking market share and financial pressures facing nonprofit and independent dialysis facilities for safety net–reliant patients with ESKD in the United States. Disclosures None. Funding The authors report funding from National Institute of Diabetes and Digestive and Kidney Diseases grant R01DK113398-01.