Costs of Care Rise Rapidly with CKD Progression

The costs of care for patients with chronic kidney disease (CKD) rise rapidly—even in the early stages of the disease, according to new research.

About 26 million US adults have CKD (Coresh J, et al. JAMA 2007; 298:2038–2047). Patients who progress to end stage renal disease (ERSD) require expensive care, which currently accounts for as much as 6% of Medicare spending despite such patients only making up 1% of the Medicare population. To reduce such spending, efforts to slow progression of the earlier stages of CKD have been proposed. But the costs of CKD at various stages, and the potential cost-effectiveness of slowing progression, haven’t been well studied.

A 2014 study by Amanda A. Honeycutt, PhD, and her colleagues found that estimated annual Medicare costs for CKD-associated care increase from about $0 for stage 1 patients to $1700 for stage 2, $3500 for stage 3, and $12,700 for stage 4 (Honeycutt AA, et al. J Am Soc Nephrol 2014; 24:1478–1483). Honeycutt is director of the Public Health Economics program of the nonprofit Research Triangle International.

New research shows that the all-cause costs to Medicare and private insurers for treating CKD patients rapidly increase as the disease progresses.

Ladan Golestaneh, MD, an associate professor of clinical medicine at the Albert Einstein College of Medicine in New York, and her colleagues identified patients who were prescribed a renin-angiotensin-aldosterone system inhibitor in the Humedica electronic medical record (EMR) database. Then they compared the costs of care for patients with stage 1 or higher CKD (based on diagnosis or estimated glomular filtration rate) with costs for control patients without the condition for at least 90 days.

Average claims costs from the commercial and public payers were then applied to the services and prescriptions the patients received. ERSD-related dialysis was excluded. The study, which included 93,912 patients younger than age 65 and 81,829 patients age 65 or older, was funded by Relypsa, Inc., and was presented at Kidney Week 2016 (“Healthcare Cost Rises Exponentially by Stage of Chronic Kidney Disease”).

The average estimated annual all-cause cost per patient in 2016 increased from $7500 in patients with no CKD, to $27,200 at Stage 3a, and $77,000 by stage 4–5 in patients covered by commercial insurance in the Golestaneh analysis. Among Medicare beneficiaries, the average estimated annual all-cause costs per patient were lower overall, but also increased rapidly from $8100 in CKD-free patients, to $20,500 at stage 3a, and $46,100 by stages 4–5. (Table 1)

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Although these estimates were higher than those found by Honeycutt et al. for patients with Medicare, they were consistent with a 2011 US Renal Data System report on Medicare costs across all people with diagnosed CKD. The Honeycutt study looked only at CKD-related costs of care, and controlled for other disease-related costs. Yet CKD is a marker of medically complex and severely ill patients that partially contributes to increasing costs by worsening cardiovascular outcomes, Golestaneh noted. The presence of CKD also may lead clinicians to provide more aggressive care, she said.

Another difference between the two studies is that use of EMRs in the Golestaneh study allowed for a larger sample size and analysis of costs for patients younger than age 65 as well as those older than 65.

Inpatient care and rising costs

Inpatient care contributed to the bulk of the costs for patients at every stage of kidney disease in the Golestaneh analysis, and it accounted for an increasing share of the costs in the later stages of progression. Future studies are needed to tease out which admissions are avoidable or in which situations care might be safely shifted to an outpatient setting, Golestaneh said.

“Efforts to slow CKD progression and reduce hospital admissions and readmissions are likely to be important for reducing disease morbidity and should translate into substantial cost reductions,” she said.

Diagnosis is an important first step. Many patients with CKD have historically gone undiagnosed, she said.

“Because inpatient costs increased considerably for higher CKD stages, earlier diagnosis may result in better control and a reduced likelihood of inpatient stays for CKD,” Honeycutt said.

Additional study is needed to understand whether increased awareness of the burden of CKD and ESRD has led to more diagnoses in patients before and after age 65. Policymakers may also need to find ways to boost diagnosis.

“Given historically low CKD diagnosis rates, policies to promote routine testing, especially among older adults, could lead to reduced costs and better quality of life for those with CKD, Honeycutt said.

Nephrologists also can play a central role in improving CKD care and reducing its costs.

“We need to redesign the way we care for these patients,” Golestaneh said. “We need to provide them with tools and resources such that they do not have to resort to the emergency room when they can’t reach us or when they are having problems that they cannot address without assistance. Above all we need to study them and listen to them to fully understand why [these patients] have high inpatients costs.”

April 2017 (Vol 9, Number 4)