Dialysis Facility Acquisitions and Their Impact on Operating Structure and Kidney Transplant Access

• In Event: Shifting Insurance Landscapes and Access to Care: Insights from Public and Private Insurance Markets

Abstract

Research Objective: Kidney transplantation is the preferred treatment for 550,000 Americans with end-stage renal disease (ESRD), yet most rely on dialysis. Prior research suggests that independent dialysis facilities acquired by large chains see fewer patients waitlisted. As private equity investment and consolidation in healthcare expand, understanding how facility acquisitions impact patient outcomes, particularly timely transplant access, is crucial. This study examines whether and how acquisitions influence waitlisting and transplant receipt, focusing on changes in key transplant-related milestones.

Study Design: We use a stacked difference-in-differences (DiD) approach to compare transplant access outcomes among always-chain-affiliated, always-independent, and newly acquired facilities. Outcomes include time from dialysis initiation to waitlisting, time from waitlisting to transplant, total time to transplant, and the probability of waitlisting or transplantation within one year. Standard errors are clustered at the facility level, and models adjust for patient demographics and clinical characteristics.

Population Studied: We examined 247,205 adult, incident ESRD patients and 8,321 dialysis facilities in the US from 2008 to 2018. When studying duration outcomes, we limit our sample to patients who began dialysis treatment by 2015 in order to have a 3-year follow-up period. 

Results: Of the 247,205 incident ESRD patients included in this analysis, the mean (SD) age was 62 (14), 102,670 (41.5%) were female, 128,357 (51.92%) were White, 66,256 (26.8%) were Black, and 37,179 (15.0%) were Hispanic. At incident ESRD, 24,464 (9.9%) patients were employed, 191,871 (77.6%) were reported to have received transplant information, and 115,574 (46.8%) received at least six months of nephrologist care prior to ESRD. Among these patients, 87,058 (35.2%) individuals received care in independent facilities that were acquired by chains during the study period (160,147 (64.8%) incident patients received care in always independent facilities). Facility acquisition was significantly associated with the prolonged waiting time. The average waiting time from ESRD diagnosis to waitlist placement increased by 31.7 days (95% CI, 4.9 to 58.5; p=0.021) when independent facilities acquired by chains, and the overall waiting time increased by 92 days (95% CI, 40.0 to 143.3; p = 0.001). Patients younger than 65 faced a longer waiting time from ESRD diagnosis to waitlist placement (37 days; 95% CI, 5.8 to 67.8; p=0.02) and longer overall duration (88 days; 95% CI, 30.6 to 144.8; p=0.003) after facility acquisitions compared to patients older than 65. Black incident patients experienced a significant increase in overall duration (127 days; 95% CI, 8.46 to 245.77; p = 0.04) compared to white incident patients.

Conclusions: Dialysis facility acquisitions were associated with prolonged wait times for kidney transplantation. These findings highlight the need for continued monitoring of dialysis market consolidation and policies to promote equitable, timely transplant access.

Implications for Policy or Practice: CMS aims to double kidney availability for transplant by 2030. However, increasing early waitlisting is essential to ensure timely transplantation. Barriers between dialysis initiation and waitlist placement require further investigation.

Authors

• Sih-Ting Cai, Indiana University
  Presenting Author

• Seth Freedman, Indiana University
  Non-Presenting Co-Author