Implications of Regulatory and Reimbursement Changes for the Future Success of Peritoneal Dialysis

Patients with ESRD constitute less than 1 percent of the total Medicare population but account for nearly 7 percent of dollars spent. Recognizing powerful financial incentives for the overuse of certain separately billable items, Congress mandated that the Centers for Medicare and Medicaid Services implement a per-dialysis-session expanded bundled payment in 2008. This bundled payment aims to reduce costs, attempting to pay no more than dialysis providers require to offer high-quality care. Any change in profit margin would be recognized by the dialysis provider; thus, the drive to do less as opposed to more might be incentivized by such a payment system. Also, dialysis modalities that cost less than others would be encouraged. The costs of peritoneal dialysis, not including payments to physicians, are estimated to be approximately $20,000 lower than the costs of hemodialysis, with similar outcomes noted between modalities over the first several years of therapy.

A major implication of these regulatory and reimbursement changes is the expansion of peritoneal dialysis use, reversing the trend over the past 20 years. The use of peritoneal dialysis in the United States peaked at 16 percent in 1985 and started to decline around 1994 to the current prevalence rate of 7 to 8 percent. Data showing a possible reversal of the downward trend will be forthcoming in a General Accounting Office report due in March 2013. U.S. Renal Data System data for 2011 have not yet been released, and the full impact of these changes may not be understood until well after 2012.

If the use of peritoneal dialysis grows, peritoneal dialysis units may receive additional resources, which may drive additional growth. Economies of scale may decrease costs even further. With a more comprehensive bundled payment system, dialysis providers have already shifted some of their resources to promote peritoneal dialysis as an underused modality. Even before the reimbursement changes, large dialysis organizations recognized the benefit of having an expanded home dialysis program.

Another relevant regulatory change was the addition of the Medicare education benefit in January 2010. Providers are now reimbursed for up to six sessions to educate patients with stage 4 chronic kidney disease about dialysis options, which may drive an increased use of peritoneal dialysis. In one study of 1600 ESRD patients surveyed, of the 61 percent who were counseled about all dialysis options, 11 percent started peritoneal dialysis. Of the 39 percent not counseled, only 1.6 percent started peritoneal dialysis.

With further resources and more education benefits, providers may have a greater percentage of their patients begin with peritoneal dialysis rather than with hemodialysis. More patients who are less fit as candidates for peritoneal dialysis may be swayed to start it. Interestingly, this may increase the expense of peritoneal dialysis and narrow the gap between the expenses of one dialysis modality versus another.

Last, with these regulatory and reimbursement changes and the potential increase in use of peritoneal dialysis, the workforce needs to be prepared to care for these patients. Better provider education may expand the use of peritoneal dialysis. Studies have shown that nephrology fellowship trainees have much less exposure than their Canadian counterparts and than historical control individuals, given the decreased use of peritoneal dialysis in this country. Groups such as the International Society of Peritoneal Dialysis and the American Society of Nephrology have recognized this and have made concerted efforts to create and sponsor additional educational experiences, such as a peritoneal dialysis curriculum and focus groups among the directors of nephrology fellowship training programs.

In this changing practice environment, many opportunities exist to expand peritoneal dialysis. As a community we should promote these changes in the most thoughtful way to provide care for our patients, who cannot always advocate for themselves. Through active education of patients and providers, close communication with policy makers and dialysis providers, and conscientious monitoring of the effects of these changes, we can encourage the optimal provision of peritoneal dialysis in this country.


[1] Suzanne Watnick, MD, is associate professor of medicine and fellowship program director at the Oregon Health and Science University in Portland, OR.

Suggested Reading

1.Collins AJ, Foley RN, Herzog C, et al. U.S. Renal Data System 2010 Annual Data Report. Am J Kidney Dis 2011; 57(1 Suppl 1):A8, e1–526.

2.Medicare program; end-stage renal disease prospective payment system. Final rule. Fed Regist 2010; 75:49029–49214.

3.Mehrotra R, Chiu YW, Kalantar-Zadeh K, et al. Similar outcomes with hemodialysis and peritoneal dialysis in patients with end-stage renal disease. Arch Intern Med 2011; 171:110–118.

4.Kutner NG, Zhang R, Huang Y, et al. Patient awareness and initiation of peritoneal dialysis. Arch Intern Med 2011; 171:119–124

5.Johansen KL. Choice of dialysis modality in the United States. Arch Intern Med 2011; 171:107–109.

6.Jain A, Blake P, Cordy P, et al. Global trends in rates of peritoneal dialysis. J Am Soc Nephrol 2012; 23:533–544.

7.Pulliam J, Hakim R, Lazarus M. Peritoneal dialysis in large chains. Perit Dial Int 2006; 26:435–437.

8.Berns JS. A survey-based evaluation of self-perceived competency after nephrology fellowship training. Clin J Am Soc Nephrol 2010; 5:490–496.

9.Mehrotra R, Blake P, Berman N, et al. An analysis of dialysis training in the United States and Canada. Am J Kidney Dis 2002; 40:152–160.

August 2012 (Vol. 4, Number 8)