Trends in Dialysis Industry Consolidation After Medicare Payment Reform, 2006-2016

Caroline E Sloan,Virginia Wang,Justin G Trogdon,Cynthia J Coffman,Matthew L Maciejewski,Abby Hoffman

doi:10.1001/jamahealthforum.2021.3626

Abstract

The dialysis industry is highly concentrated, with large dialysis organizations now providing dialysis for more than 85% of patients with kidney failure in the United States. In 2011, Medicare introduced a new Prospective Payment System (PPS) for end-stage kidney disease, which bundled payment for dialysis care into 1 payment per patient. Trends in dialysis facility consolidation after the PPS went into effect are unknown. To determine whether the introduction of the PPS in 2011 was associated with an acceleration in acquisitions and closures of small dialysis chains (<20 facilities) and independently owned facilities. This retrospective cohort study included all Medicare-certified independent or small chain-affiliated dialysis facilities in the continental US between 2006 and 2016. Data were obtained from Medicare and the US Renal Data System and were analyzed in 2020. The PPS. Discrete time hazard models were used to estimate the odds of acquisition and closure before the PPS (2006-2010) vs after the PPS (2011-2016). Analyses controlled for facility, market, and regional demographic characteristics. The average predicted marginal probabilities of acquisition and closure over time were estimated. The proportion of small chain-affiliated and independently owned facilities declined from 29% (1383 of 4750 facilities) in 2006 to 15% (1038 of 6738) in 2016. Among 13 481 facility-years, 6352 (47%) were for profit, and mean (SD) census was 68 (59) patients. Overall, 3286 (24%) facilities opened during the observation period. The proportion of acquisitions that occurred each year varied from 1.1% (12 of 1065 facilities in 2015) to 7.2% (86 of 1192 facilities in 2012), while closures varied from 0.8% (9 of 1065 facilities in 2015) to 2.2% (28 of 1286 facilities in 2010), making both fairly rare. There was a 3.48 higher odds of acquisition in the post-PPS period compared with the pre-PPS period (95% CI, 1.62-7.47; P = .001). The odds of closure before and after the PPS were not statistically significantly different (odds ratio, 2.03; 95% CI, 0.61-6.73; P = .25). Facilities that opened during the observation period had a 7.2% higher predicted probability of acquisition compared with older facilities (95% CI, 5.4%-9.0%; P < .001). In this cohort study of continental US Medicare-certified dialysis facilities, small-chain and independently owned facilities retained a declining share of the dialysis market. Further research should evaluate the effect of continued dialysis market consolidation on patient access, health care utilization, and clinical outcomes.

Highlights

IntroductionDialysis facilities in the United States currently treat more than 700 000 patients with end-stage kidney disease (ESKD).[1] The dialysis industry has become highly concentrated over the past 2 decades, transitioning from an industry dominated by 5 large dialysis organizations (LDOs; Ն20 facilities) in the early 2000s to a duopoly dominated by 2 for-profit LDOs today.[2,3] Patients receiving dialysis at facilities affiliated with for-profit LDOs have lower survival rates than patients receiving dialysis at smaller nonprofit chains and independent facilities.[4] Dialysis facility acquisitions have been shown to have negative associations with clinical care and patient outcomes.[3,5] Independent facilities that were acquired by LDOs in 2005, for instance, lowered their staff-to-patient ratios, reduced referrals for kidney transplant, and increased use of expensive injectable drugs.[3] Hospitalizations for bacteremia and death increased after acquisition.[5,6,7]
There was a 3.48 higher odds of acquisition in the post-Prospective Payment System (PPS) period compared with the pre-PPS period
Further research should evaluate the effect of continued dialysis market consolidation on patient access, health care utilization, and clinical outcomes

Summary

Introduction

Dialysis facilities in the United States currently treat more than 700 000 patients with end-stage kidney disease (ESKD).[1] The dialysis industry has become highly concentrated over the past 2 decades, transitioning from an industry dominated by 5 large dialysis organizations (LDOs; Ն20 facilities) in the early 2000s to a duopoly dominated by 2 for-profit LDOs today.[2,3] Patients receiving dialysis at facilities affiliated with for-profit LDOs have lower survival rates than patients receiving dialysis at smaller nonprofit chains and independent facilities.[4] Dialysis facility acquisitions have been shown to have negative associations with clinical care and patient outcomes.[3,5] Independent facilities that were acquired by LDOs in 2005, for instance, lowered their staff-to-patient ratios, reduced referrals for kidney transplant, and increased use of expensive injectable drugs.[3] Hospitalizations for bacteremia and death increased after acquisition.[5,6,7]

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Conclusion