Stroupe KT (Midwest Center for Health Services and Policy Research)
Hynes DM (Midwest Center for Health Services and Policy Research)
Browning MM (Midwest Center for Health Services and Policy Research)
Kaufman JS (VA Boston Healthcare System)
Reda DJ (Hines Cooperative Studies Program Coordinating Center)
Peterman A (Northwestern Center on Outcomes, Research and Education)
Huo Z (Northwestern Feinberg School of Medicine)
Veterans with end-stage renal disease (ESRD) require chronic dialysis to replace lost kidney function, and most become eligible for Medicare three months after initiating dialysis. Consequently, veterans may receive dialysis care in either the VA or private-sector. However, Medicare only covers 80% of healthcare expenses; typically $50,000 annually for ESRD patients. Although Medicare supplemental insurance is necessary for patients to avoid financial burdens of private-sector care, the association between health insurance coverage and dialysis venue is not well understood. We examined these issues among veterans with ESRD.
Data were from a VA HSR&D-funded multi-site prospective observational study of hemodialysis patients at 8 VA facilities in 2001-2003 to examine costs and outcomes of veterans dialyzing at VA versus private-sector facilities; 326 patients were enrolled. Data included information on patients’ health insurance outside the VA from all sources, demographic (age, race), geographic (distance to closest VA hospital) and clinical factors (primary cause of ESRD, months on dialysis, hemoglobin, albumin). Using multivariable logistic regression, we examined the association of health insurance (VA only; VA and Medicare; VA, Medicare and supplemental) with the likelihood of dialyzing at the VA at enrollment in the study, controlling for demographic, geographic and clinical factors.
Veterans with VA, Medicare, and supplemental coverage were 96% less likely to receive dialysis at a VA (OR=0.04; 95% CI: 0.01-0.17; p <.0001) than veterans with VA coverage only. In contrast, veterans with VA and Medicare coverage were 72% less likely (OR = 0.28; 95% CI: 0.06-1.25; p = 0.11) to receive dialysis at a VA. Additionally, older veterans and veterans living farther from a VA were less likely to dialyze at the VA.
Although most veterans become eligible for Medicare coverage after initiating dialysis, we found that veterans with only Medicare coverage were less likely than those with supplemental coverage to go outside VA for dialysis care.
Because veterans with ESRD are eligible for Medicare, VA policymakers may consider transferring expensive dialysis care from VA to Medicare-covered facilities. However, policymakers must address the gap in Medicare coverage for ESRD care that shifts financial burden to patients.