Early Delays in Insurance Coverage and Long-term Use of Home-based Peritoneal Dialysis
Early Delays in Insurance Coverage and Long-term Use of Home-based Peritoneal Dialysis
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DOI：
10.1097/mlr.0000000000001350
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发表时间：
2020-07-01
期刊：
影响因子：
3
通讯作者：
Lakdawalla, Darius
中科院分区：
文献类型：
--
作者：
Lin, Eugene;Chertow, Glenn M.;Lakdawalla, Darius
背景：未投保的终末期肾病患者面临腹膜透析（PD）的障碍，腹膜透析是一种与改善生活质量和降低医疗保险成本相关的家庭透析。虽然在透析开始时使用PD的未保险患者获得所需的透析前服务的追溯医疗保险覆盖，但该覆盖仅适用于透析开始的日历月。因此，在本月晚些时候开始透析可以获得更长的追溯性覆盖。目的：研究追溯性医疗保险的差异是否与长期PD使用减少有关。研究设计：我们利用来自美国肾脏数据系统的国家队列的回归不连续设计来研究透析开始日期。对象：36,256名在2006年1月1日至2014年12月31日期间开始透析的未参保成年人。测量：透析第1,90,180和360天PD使用情况。结果：在日历月的第一天与最后一天开始透析与PD使用绝对减少2.7%相关[95%置信区间（CI）， 1.5%-3.9%]，或在透析第360天相对减少20% （95% CI, 12%-27%）。在2011年Medicare建立了PD的提供者激励机制后，绝对降幅为5.5% (95% CI, 3.5%-7.2%)，在2014年Medicaid扩张后，绝对降幅为7.2% （95% CI, 2.5%-11.9%）。患者在透析的第一个月后不太可能从血液透析转向PD（第1个月的概率为6.9%，第2个月为1.5%，第4个月为0.9%）。结论：扩大预备透析服务的追溯覆盖范围可以增加PD的使用并减少未参保的总体医疗保险支出。
Background: Uninsured patients with end-stage renal disease face barriers to peritoneal dialysis (PD), a type of home dialysis that is associated with improved quality of life and reduced Medicare costs. Although uninsured patients using PD at dialysis start receive retroactive Medicare coverage for required predialysis services, coverage only applies for the calendar month of dialysis start. Thus, initiating dialysis later in the month yields longer retroactive coverage. Objectives: To examine whether differences in retroactive Medicare were associated with decreased long-term PD use. Research Design: We exploited the dialysis start date using a regression discontinuity design on a national cohort from the US Renal Data System. Subjects: 36,256 uninsured adults starting dialysis between January 1, 2006 and December 31, 2014. Measures: PD use at dialysis days 1, 90, 180, and 360. Results: Starting dialysis on the first versus last day of the calendar month was associated with an absolute decrease in PD use of 2.7% [95% confidence interval (CI), 1.5%-3.9%], or a relative decrease of 20% (95% CI, 12%-27%) at dialysis day 360. The absolute decrease was 5.5% (95% CI, 3.5%-7.2%) after Medicare established provider incentives for PD in 2011 and 7.2% (95% CI, 2.5%-11.9%) after Medicaid expansion in 2014. Patients were unlikely to switch from hemodialysis to PD after the first month of dialysis (probability of 6.9% in month 1, 1.5% in month 2, and 0.9% in month 4). Conclusions: Extending retroactive coverage for preparatory dialysis services could increase PD use and reduce overall Medicare spending in the uninsured.