Commercial Health Insurance and Quality of Care in US Dialysis Facilities

Rationale & Objective

Commercial health insurance typically reimburses at a higher rate for dialysis than Medicare. A recent ruling by the US Supreme Court could result in many commercially insured patients who receive dialysis forgoing their private health insurance and shifting to Medicare as the primary payer. Our objective was to determine whether differences in commercial payers as a proportion of payer mix affect the quality of care at dialysis facilities.

Study Design

Cross-sectional study.

Setting & Population

We examined US patients receiving dialysis from US Dialysis Facility Reports and the Dialysis Facility Compare websites in 2019.

Exposures

Percentage of prevalent dialysis patients with commercial health insurance.

Outcomes

Seven key dialysis facility quality metrics included in Dialysis Facility Compare star ratings.

Analytical Approach

Multivariable linear regression models adjusted for observed confounders.

Results

Among 7,194 US dialysis facilities, an average of 4.4% of prevalent dialysis patients had commercial insurance. Each 10% absolute increase in the percentage of dialysis patients in a facility with commercial insurance was associated with an adjusted 8.3% (3.0%-13.6%) lower standardized mortality ratio. Commercial health insurance was not significantly associated with the remaining quality metrics examined, including standardized fistula rate, long-term catheter rate, standardized hospitalization ratio, standardized transfusion ratio, dialysis adequacy, and In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems patient experience score.

Limitations

The potential for unobserved confounders including social risk factors limits the ability to make causal inferences.

Conclusions and Relevance

Dialysis facilities with a higher percentage of patients with commercial health insurance had better performance in standardized mortality ratio. If this association reflects a causal connection, then increased shifting of coverage from commercial health insurance to Medicare could adversely affect the quality of care at dialysis facilities.

Plain Language Summary

A recent US Supreme Court decision may lead US patients receiving dialysis to shift from commercial health insurance to Medicare. Our objective was to determine whether differences in commercial payers as a proportion of dialysis facility payer mix affect the quality of care at dialysis facilities. In an analysis of dialysis facility quality ratings from 2019, more commercial insurance was associated with better performance in standardized mortality ratio but not with other key dialysis facility quality measures. This finding suggests that the shifting of coverage from commercial health insurance to Medicare could adversely affect quality of care at US dialysis facilities.