Utilization, costs, and outcomes for patients receiving publicly funded hemodialysis in India

Abstract

Every year about 150,000 people develop end stage kidney disease (ESKD) in India, most of whom die without receiving treatment. In 2008, the state of Andhra Pradesh started public funding for hemodialysis (HD). We evaluated the coverage pattern, cost of care and outcomes of patients treated under this scheme. Unique identifiers and billing codes for HD, vascular access and hospitalisation were identified from claims database to construct utilisation, cost and outcome for subjects from 2008 to 2012. Outcomes were classified as death, dialysis discontinuation and kidney transplantation. Costs of HD, vascular access, and hospitalizations were calculated. A total of 13,118 beneficiaries (1.36% of all claimants, mean age 44 years, 73% males) received HD during the study period. The number of people who received HD increased from 29.5 pmp in 2008-09 to 122.2 pmp in 2012-13. Of all patients, 10% died and 37% dropped out in first 6 months. Median time on HD was 170 and 198 days for females and males respectively (p=0.0059). Mortality increased with age and was higher in women and in public hospitals. The average per patient annual expenditure on HD was US$ 4,820. Costs of HD as a proportion of the total healthcare spend increased from 0.78% in 2008-09 to 5.15% in 2011-12. Progressive increase in uptake confirms a high unmet need for renal replacement therapy. High mortality and dropouts suggest the contribution of factors beyond user fees to outcomes. Insurance coverage does not address all inequities in access and the barriers to maintaining long term dialysis care.

Cost estimate of chronic hemodialysis in Kinshasa, the Democratic Republic of the Congo: A prospective study in two centers

“…Although it is difficult to compare analyses carried out at different centers (cost evaluation depends on a variety of factors), the mean annual expenditure per patient on HD-related care in US$ is 28,280 in Kinshasa, which is significantly higher than that reported in Cameroon (U $13,581), 23 Morocco (US$12,000), 11 lran (US$11,549) 24 and India (US$4821) 25 but similar to the annual cost reported in Brazil (US$28,570) 26 and Tanzania (US$27,440). 27 This annual expense per Congolese HD patient is, however, relatively lower than the HD cost from other countries (€81,500 in France, 16 US$68,000 in the USA 13 and US$46,332 in Saudi Arabia 28 ).…”

Increasing access to integrated ESKD care as part of universal health coverage

“…Experience from some jurisdictions that have introduced state-funded dialysis shows that other components of dialysis delivery that result in OOP expenditures (no matter how small their contribution) culminate in catastrophic health care expenditure and premature withdrawal from dialysis, thereby preventing attainment of equity. 86 Recognizing the need for reform, the government of the state of Andhra Pradesh in India provides a monthly grant of INR 2500 (US $35) through direct cash transfer to offset OOP expenses incurred on dialysis. 87 Many countries have several different reimbursement schemes to fund KRT, which also diminish progressivity and perpetuate inequities in access to and outcomes of KRT.…”

“…In a state-funded dialysis scheme in India, the female-to-male ratio was 1:3.5. 86 Countries that have committed to supporting broad-based dialysis programs are likely to experience increase in demand as the financial barrier is removed, which will force identification of new revenue sources (taxes), or disinvestment in other services. Alongside financing issues, governance and organizational factors need to be taken into account to optimize equitable use of limited resources when providing expensive ESKD care.…”

“…While PPPs have permitted ESKD care services to expand, 86 there are few studies that have evaluated their ability to deliver efficiency gains in countries where access and equity are major concerns. The function of PPPs in LMICs can be further hampered by lack of strong governance and monitoring mechanisms, misbehavior of market forces, contract disputes, and lack of dispute resolution mechanisms.…”

Methodological challenges to collecting clinical and economic outcome data: Lessons from the pilot dialysis outcomes India study

“…In recent years, many developing countries, including India, have started offering access to dialysis as part of universal health coverage programmes . This opening up of access has seen an increase in the number of patients on dialysis . However, data on the outcomes and on the sustainability of such treatment in a country with low personal incomes and a limited social safety net is scarce.…”