Bundled Payment Reform and Dialysis Facility Closures in ESKD

J Am Soc Nephrol. 2020 Mar;31(3):579-590. doi: 10.1681/ASN.2019060575. Epub 2020 Feb 4.


Background: In 2011, inclusion of injectable medications into an expanded ESKD payment bundle prompted concerns that dialysis facilities facing higher costs might close, disrupting care delivery and access to care. Whether this policy change influenced dialysis facility closures is unknown.

Methods: To examine whether facility closures increased after 2011 and whether factors influencing closures changed, we analyzed US Renal Data System registry data to identify all patients receiving in-center hemodialysis from 2006 through 2015 and to track dialysis facility closures. We used interrupted time series logistic regression models and estimated marginal effects to examine immediate and longer-term changes in the likelihood of being affected by facility closures following payment reform. We also examined whether associations between selected predictors of closures indicating populations at "high risk" of closure (patient characteristics, facility characteristics, and geography-related characteristics) and closures changed after payment reform.

Results: Dialysis facility closures were uncommon over the study period. In adjusted models, the relative odds of experiencing a closure declined by 37% (odds ratio [OR], 0.63; 95% confidence interval [95% CI], 0.59 to 0.67) immediately after payment reform and declined by an additional 6% (OR, 0.94; 95% CI, 0.91 to 0.97) annually thereafter, corresponding to a 0.3% lower absolute probability of closure in 2015 in association with payment reform. Patients who were black and who dialyzed at small, hospital-based facilities experienced slight increases in closures following payment reform, whereas Hispanic and Medicare/Medicaid dual-eligible patients experienced slight decreases in closures.

Conclusions: Expansion of the ESKD payment bundle was not associated with increased closure of dialysis facilities, although the likelihood of closures changed slightly for some higher-risk populations.

Keywords: Chronic dialysis; Economic impact; Epidemiology and outcomes; Ethnic minority; United States Renal Data System.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Female
  • Health Care Costs
  • Health Care Reform / economics
  • Health Facility Closure / economics
  • Health Facility Closure / statistics & numerical data*
  • Hemodialysis Units, Hospital / economics*
  • Hemodialysis Units, Hospital / statistics & numerical data
  • Humans
  • Kidney Failure, Chronic / diagnosis
  • Kidney Failure, Chronic / therapy*
  • Male
  • Middle Aged
  • Prospective Payment System / economics*
  • Registries*
  • Renal Dialysis / economics*
  • Renal Dialysis / methods
  • Retrospective Studies
  • United States