Patients With CKD Incur the Highest Out-of-Pocket Expenses

Tejas P. Desai, MD


March 03, 2017

Non-dialysis Dependent Chronic Kidney Disease Is Associated With High Total and Out-of-Pocket Healthcare Expenditures

Small C, Kramer HJ, Griffin KA, et al
BMC Nephrol. 2017;18:3.

One of the most shocking aspects of end-stage renal disease is the disproportionate use of financial resources for the number of dialysis-dependent patients. Recent figures indicate that 0.5% of the US population requires chronic dialysis and that nearly 7% of Medicare funds are required to sustain this small fraction of patients. In fact, the total direct cost to care for both dialysis-dependent and independent patients is one of the highest among all chronic medical conditions. Only patients with cancer or stroke therapy incur a similarly high amount of expenditures. No one disputes that such high costs place a considerable financial strain on our healthcare system, but some may be unfamiliar with the burdensome costs that these chronic medical conditions place on individual patients. This study looked at the total and out-of-pocket health expenditures incurred by adults with these three conditions and hypothesizes that the personal cost of managing kidney disease is greater than that for cancer or stroke.


The patients analyzed in this investigation were survey respondents to the Medical Expenditures Panel Survey (MEPS). MEPS is an annual survey that collects self-reported data on various medical- and financial-related healthcare parameters of patients in the United States. The survey data analyzed were collected between the years 2011 and 2013 (inclusive) and contained data from 74,452 adults at least 21 years of age. The survey asked respondents to indicate their chronic medical conditions and how much of their own money was spent on co-insurance, meeting their insurance deductibles, and any other personal financial expense not covered by their insurance in the treatment of their conditions. The investigators partitioned the respondents into one of four mutually exclusive groups: those having (1) nondialysis chronic kidney disease (CKD) (of any stage); (2) breast, lung, and/or colon cancer; (3) stroke or transient ischemic attack(s); or (4) none. A comparison was made between the median and interquartile ranges (IQR) of the reported amount spent in each group.

Of the respondents, only 52 had nondialysis CKD (0.07%), 870 (1.2%) had cancer, and 1104 (1.5%) had stroke. Their self-reported data indicated that patients with nondialysis CKD had the highest personal financial expenditures—$1439 (IQR: $688-$2732). Patients with stroke had the lowest out-of-pocket expenditures—$748 (IQR: $242-$1559). Patients with cancer had expenditures similar to those of patients with stroke—$770 (IQR: $349-$1703). When considering their personal incomes, patients with nondialysis CKD had the largest proportion of their incomes diverted towards healthcare compared with patients with cancer or stroke (7.2% vs 5.1% and 5.9%, respectively).


Startling as these results are, it is my humble opinion that this study does not appropriately answer the hypothesis that patients with nondialysis CKD spend more of their personal income on their medical care compared with patients with cancer or stroke. The investigation is an admirable effort that is hampered by multiple obstacles which, in and of themselves, might not lessen the validity of the findings. Collectively, however, I feel that these hurdles negatively affect the interpretation of this study. First, the study introduces all of the negatives found in investigations that rely on survey data. Second, the survey does not adequately represent the overall population, with < 1% of respondents afflicted with nondialysis CKD. Third, the investigation analyzes self-reported income and healthcare expenditures, further introducing bias into the results. Fourth, at least 2.5 times as many patients with nondialysis CKD reported not having any health insurance compared with patients with stroke or cancer (8.1% vs 3.2% and 2.0%, respectively). Fifth, while the authors indicate that they adjusted their data to be more representative of the general population, I was unable to find detailed information in the text or supplemental files to indicate how the adjustment was performed.

While we may be inclined to thinking that out-of-pocket expenses for patients with nondialysis CKD are higher than for patients with cancer or stroke, the hurdles inherent in this study make it hard for me to quantify this "gut feeling." (Figure)

Figure. Medical expenses. Image courtesy of Tejas Desai, MD

What about you? Tell us what you think in the comments.


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