Medicare Payment Squeeze Hardship on Rural Dialysis Patients

Daniel M. Keller, PhD

November 13, 2011

November 13, 2011 (Philadelphia, Pennsylvania) — With reductions this year in Medicare payments to dialysis clinics for the treatment of end-stage renal disease, many clinics could close and many dialysis patients might have to find a new dialysis facility, adding substantially to their travel burden in miles and time, according to a presentation at a news conference here at Kidney Week 2011: American Society of Nephrology 44th Annual Meeting.

Patients in rural areas will be most severely affected, reported healthcare researcher Mark Stephens, from Prima Health Analytics in Boston, Massachusetts.

As Medicare continues to modify its bundled payment system for the treatment of end-stage renal disease, patients could have reduced access to care, diminished quality of care and quality of life, and increased mortality. Mr. Stephens and colleagues sought to estimate the incremental distances and travel time that dialysis patients might incur.

"If 150 facilities were to close, which is about 3% of all facilities in the United States over 3 years, or 1% a year, about 10,000 patients would be affected. Our estimate is that they would end up traveling roughly an additional 15 million miles for dialysis care," Mr. Stephens said, and 13 million of those miles would be traveled by suburban and rural patients. Long travel times and distances can be a large burden for patients and their families in terms of finances and quality of life.

Some dialysis clinics have already closed because of financial pressures. Up to 20% of today's clinics are expected to lose up to 10% or more of their Medicare income, according to estimates of the Centers for Medicare and Medicaid Services.

"Rural facilities are probably at greater risk of closing," Mr. Stephens said. "They typically lose money every year on their Medicare business." These facilities have less ability to respond to payment reductions because they cannot add new patients, their costs are typically higher than urban centers, and they do not have adequate financial reserves.

Greater Travel Time and Distance Burdens

Based on 50 closures a year, which is the historic average of the past 4 years, "the average patient will have to travel roughly an extra 5.5 miles per treatment," Mr. Stephens estimated. "That doesn't sound like a whole lot, but in rural areas and suburban areas, patients would have to travel about an extra 25 miles." That amounts to more than 3500 additional miles yearly. Typically now, patients travel about 8 miles round-trip, and about 30 miles in rural areas.

To validate their model, the Prima Analytics investigators compared their figures with those of Medpac, which advises the US Congress on Medicare issues. The Prima figures were in line with Medpac's current estimates of actual travel distances. For urban patients, the extra distance would only be about 0.6 miles per treatment, or 84 miles/year.

Mr. Stephens said previous research has shown that patients who have to travel more than 15 minutes each way for dialysis have a lower quality of life and higher mortality rates. Although the differences in travel distances for urban patients would be small if they had to go to an alternative facility, rural patients would be severely affected. About 22% now travel less than 16 minutes 1 way, but under the modeled closures, only 2% would have a commute this short in the future, 25% would travel 16 to 30 minutes, and 73% would have to travel more than 30 minutes.

"Those are the distances over which quality of life tends to decline and mortality tends to be higher," Mr. Stephens reported. "Ninety-eight percent of them are going to be traveling more than 15 minutes to dialysis."

Based on the predicted facility closures and consolidations and the current average number of patients at each facility, about 10,000 patients, or 2.5% of the current dialysis population, would be affected. Although this is not a large percentage of the total dialysis patient population, it would disproportionately affect people in rural areas. Mr. Stephens said that some patients in those areas travel up to 6 hours for each dialysis session. In northwestern Kansas, they have to go about 180 miles, and in northeastern Colorado, the round-trip distance is an average of 180 miles.

Medicare already spends about $1 billion a year on transportation for dialysis patients, and Medicaid spends upwards of $2 billion on nonemergency travel, a large proportion of which is for dialysis. "So government programs are going to see a cost impact, and patients are going to see an impact in terms of cost of the additional miles," Mr. Stephens predicted.

Given the vulnerabilities of rural patients, the investigators suggest that the geographic access challenges of these patients should be more closely monitored. There is already a focus in Washington on issues of rural access to healthcare.

The study was sponsored by Amgen Inc. Mr. Stephens is an employee of Prima Health Analytics.

Kidney Week 2011: American Society of Nephrology 44th Annual Meeting: Abstract SA-PO2640. Presented November 12, 2011.


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