ESRD Population Reaches Record High

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The U.S. end-stage renal disease population reached a new high in 2008 at 547,982 people with a total cost of $39.5 billion, according to the recently released U.S. Renal Data System’s 2010 Annual Data Report.

Medicare’s ESRD spending reached $26.8 billion in 2008, and non-Medicare spending reached $12.7 billion, bringing the total cost of ESRD care to $39.5 billion.

In 2008, ESRD costs represented 5.9 percent of the overall Medicare budget. That is a decline; however, the USRDS pointed out that it is because there has been a greater growth in Medicare costs compared to ESRD costs (16.9 percent vs. 4.9 percent), and that Part D drugs benefits were included in Medicare costs.

Click HERE to access the report. 

“Costs for CKD patients are now 23 percent of Medicare expenditures in the fee-for-service sector; when added to the costs for ESRD patients, it appears that 31 percent of all Medicare expenditures are incurred by patients with a diagnosis of kidney disease,” according to the USRDS report.

Spending on each person annually rose 7.3 percent in 2008; this was the largest single year increase since 1992, according to the USRDS report.  Medicare spent an average of $66,000 per ESRD patient, ranging from $26,668 for transplant patients to $77,506 for hemodialysis patients, according to the report.

The number o f new dialysis patients rose slightly in 2008 at 1.2 percent, or 108,926 new patients, according to the USRDS report. The growth between 2006 and 2007 was 0.85 percent.

“Despite the high disease burden, the rate of progression to ESRD has been relatively stable over the last several years, suggesting either that CKD patients are dying at a higher rate before they reach ESRD or that their rate of progression to ESRD has slowed,” the researchers wrote in the USRDS report. “The continuing decline in rates of death from cardiovascular disease (the major cause of mortality in the CKD population), along with improved treatment and control of hypertension and increased use of ACEs/ARBs/rennin inhibitors suggest that progression of CKD to ESRD may indeed have slowed.”

Peritoneal dialysis made up 6 to 7 percent of the dialysis population in 2008, down from peaks of 12 to 18 percent in the 1980s and 1990s, according to the USRDS report.

The number of kidney transplant reached 17,413 in 2008, and the median time on the kidney-only wait list was 732 days. That number of transplants included 5,968 from living donors.

Drug Spending

Medicare’s spending on erythropoiesis-stimulating agent (ESA) fell in 2008, largely due to clinical studies about the risk of ESAs, as well as new policies to curb use. In all, Medicare spent $1.8 billion in 2008 on erythropoiesis-stimulating agent (ESA), which was a 2.3 percent decrease.

However, the cost of IV vitamin D hormone increased 12 percent to $491 million, according to the report. In addition, the cist of IV iron rose 4.8 percent to $267 million. 

More specifically, the yearly costs per person for Abbott Laboratories’ Zemplar in 2008 was $1,952, which was “considerably higher than costs for the other main types of IV vitamin D,” the USRDS wrote in the report.

Year patient costs for IV iron were $792 for Watson’s Ferrlecit, $719 for American Regent’s/Fresenius’ Venofer, and $198 for Watson’s InFed, according to the USRDS report.

The costs for phosphate binders were relatively high for dialysis patients, according to the USRDS. In 2007, the monthly net costs for sevelamer ranged from $53 in dialysis patients 75 years and older to $112.75 for patients age 20 to 44.

Also, total Part D spending reached $51.3 billion in 2007 for Medicare. ESRD patients accounted for 2.4 percent of these costs, or $1.3 billion.

Pre-ESRD Care, Vascular Access

Fifty-seven percent of new ESRD patients had some form of pre-ESRD care, and just 25 percent received care for more than 12 months. According to the USRDS, a little more than 26 percent of new patients were on erythropoiesis-stimulating agent (ESA) therapy prior to ESRD, and just 7.9 percent received ESAs for more than 12 months. In addition, less than one in 10 new patients received any pre-ESRD dietary care.

In addition, catheters remained the most common access at the first outpatient dialysis treatment at 64.8 percent in 2008, according to the USRDS. In 15.3 percent of patients, the catheter is accompanied by a maturing fistula.

The annual costs per person for vascular access events were highest in patients with an AV graft or catheter, reaching $8,683 and $6,402 in 2008. Costs for patients with an AV fistula, in contrast, were $3,480—60 percent lower than those for AV graft patients.

Provider Landscape

By the end of 2008, the USRDS reported that 117,000 patients were being treated by Fresenius, and 104,000 patients were being treated by DaVita. In addition, 13,000 were treated by Dialysis Clinics Inc. (DCI). The USRDS considered these three providers at large dialysis organizations (LDOs).

Small dialysis organizations (SDOs) treated 33,084 patients in 438 clinics, and independently owned dialysis clinics treated 63,952 patients at 927 units. Hospital-based units treated the remaining 39,759 patients at 806 clinics.

In addition, the percentage of units remaining under consistent ownership for five or more years fell from 70.6 percent in 2003 to 55.8 percent in 2008. This was a reflection of the acquisitions DaVita and Fresenius made in 2005 and 2006.

“It appears, however, that purchases of independent and hospital-based units by the large chains may be slowing,” the USRDS wrote in the report. “In 2003, for example, 57.9 percent of independent units were under the same ownership for five or more years, compared to 62.4 percent in 2008; in hospital-based units, 87.5 percent were owned for five or more years in 2003 compared to 90.0 percent in 2008.”

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