A Comparison of US Medicare Expenditures for Hemodialysis and Peritoneal Dialysis

Significance Statement Observations that peritoneal dialysis (PD) may be an effective, lower-cost alternative to hemodialysis for treating ESKD led to US policies resulting in its increased use. The authors compared Medicare expenditures for patients who started in-center hemodialysis or PD between 2008 and 2015 and determined whether differences in expenditures across dialysis modalities persisted as more patients were placed on PD. Overall expenditures were 11% greater for hemodialysis versus PD, and this difference did not change over time as more patients initiated PD. Although estimated intravenous dialysis drug costs were higher for hemodialysis, this difference narrowed over time—possibly mitigating incentives for providers to start more patients on PD and explaining a recent plateauing of growth in initiating this dialysis modality in the United States. Background Observations that peritoneal dialysis (PD) may be an effective, lower-cost alternative to hemodialysis for the treatment of ESKD have led to policies encouraging PD and subsequent increases in its use in the United States. Methods In a retrospective cohort analysis of Medicare beneficiaries who started dialysis between 2008 and 2015, we ascertained average annual expenditures (for up to 3 years after initiation of dialysis) for patients ≥67 years receiving in-center hemodialysis or PD. We also determined whether differences in Medicare expenditures across dialysis modalities persisted as more patients were placed on PD. We used propensity scores to match 8305 patients initiating PD with 8305 similar patients initiating hemodialysis. Results Overall average expenditures were US$108,656 (2017) for hemodialysis and US$91,716 for PD (proportionate difference, 1.11; 95% confidence interval [CI], 1.09 to 1.13). This difference did not change over time ( P for time interaction term=0.14). Hemodialysis had higher estimated intravenous (iv) dialysis drug costs (1.69; 95% CI, 1.64 to 1.73), rehabilitation expenditures (1.35; 95% CI, 1.26 to 1.45), and other nondialysis expenditures (1.34; 95% CI, 1.30 to 1.37). Over time, initial differences in total dialysis expenditures disappeared and differences in iv dialysis drug utilization narrowed as nondialysis expenditures diverged. Estimated iv drug costs declined by US$2900 per patient-year in hemodialysis between 2008 and 2014 versus US$900 per patient-year in PD. Conclusions From the perspective of the Medicare program, savings associated with PD in patients ≥67 years have remained unchanged, despite rapid growth in the use of this dialysis modality. Total dialysis expenditures for the two modalities converged over time, whereas nondialysis expenditures diverged.